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Re: Author's reponse to commentary on diarrhoea guidelines

Dear Editor,

We would like to respond to the commentary on our paper above.[1,2]

The following points require clarification: 1.  Dr Baumer states that 'Dr Armon and colleagues have used a formal consensus process to provide guidance...'.
The recommendations provided were evidence-based where ever evidence was available, with a formal consensus process used additionally. A systematic review of the literature was undertaken. We complied with the essential elements of a systematic review in accordance with the Scottish Intercollegiate Guidelines network. Thus the literature must be identified according to an explicit search strategy; selected according to defined inclusion and exclusion criteria; and evaluated against consistent methodological standards. [3] As is stated in the text, mesh heading and text word searching was performed.

2.  Formal consensus development was used:
a) To develop recommendations where evidence was not available. We would argue that in most guideline development processes this is the prime area of difficulty because in paediatrics, research is sparse and consensus is required for a guideline to be complete. The transparency of the development process is essential and we were explicit about which recommendations were based on consensus rather than on evidence. The Delphi method imparts greater rigour to a process that is often performed by a small selected group of individuals.
b) To act as an internal peer review. The guideline is available to a large number of participants during the development process so that any inaccuracies can be identified early on. The participants have an opportunity to check the literature grading and to inform the development group of any papers not yet identified.
c) To improve the implementation of the guideline, since the Delphi process facilitates the translation of recommendations into an algorithm which can be readily followed by clinicians. This is an important consideration in all guideline development.[4]

3.  We stated that we included scientific reviews of the literature and guidelines written by national bodies in our inclusion criteria.
The two systematic reviews references in Dr Baumer's commentary were appraised and graded as level 1 evidence since they both included sufficient detail of the methods to suggest that they were based on thorough systematic reviews of the literature. [5,6] Despite sound methodology in performing a systematic review, the evidence from the articles found still has to be translated into recommendations for putting the evidence in to practice. Formal consensus was therefore used to determine how a large body of clinicians commonly looking after children with this presenting complaint would apply the evidence found.

4.   It is important to differentiate guideline development from a Cochrane review. Established organizations who have been developing guidelines such as SIGN do not advocate hand searching and contacting of experts for unpublished studies in every circumstance.[3] This decision is left to the guideline developer and depends on the subject area. In view of the scope of this review (to produce a guideline for the child presenting to hospital with acute diarrhoea) it was impractical to perform hand searches and contact experts in the field for all the clinical questions that were addressed. At the time of the development of the guideline the RCPCH standards on guideline production did not stipulate hand searching or contacting of experts. [7]

5.  We accept that with only two nurses on the panel nursing staff views would not be fully represented. Unfortunately few of the nurses approached were prepared to take part.

6.   We would agree with Dr Baumer that primary care input is valuable and would be a useful extension of the work. At the outset, however, we limited the scope of the guideline to children presenting to hospital, in the light of previous research showing that 16% of medical presentations to hospital were with diarrhoea. [8]

7.   Parents views on admission were not sought during the Delphi process. However, we have incorporated the importance of the parents views in the guideline itself (boxes 28, 38, 43). Again parental views could be formally sought as an extension to the work.

8.  The implementation of any national guideline at local level requires modification by those who will use it and this we fully endorse.

Yours sincerely,

Dr Kate Armon

Dr Monica Lakhanpaul

Prof Terence Stephenson

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Re: Parents and children dislike nasogastric rehydration: a culture change is needed

Dear Editor,

The guidelines published by Armon et al on the management of acute diarrhoea, state that enteral rather than parenteral rehydration should be used [1]. This is in line with other recent guidance [2,3] . Despite this, children admitted to hospital are often given intravenous fluids, instead of using nasogastric rehydration.

In our district general hospital, we conducted an audit of admissions of children with gastro-enteritis and dehydration over a 1-year period (May 1999 – April 2000). We found that of 21 children admitted, none were classed as severely dehydrated on the basis of clinical examination. However 10 (48%) were given intravenous fluids and the average length of admission was 22 hours, despite guidelines supporting enteral rehydration.

To investigate why enteral rehydration was not used, we conducted a questionnaire survey of the paediatric staff (11 doctors and 17 nurses) and 35 parents of children attending the paediatric outpatient department. We asked them to rank oral (using a syringe), nasogastric and intravenous rehydration for effectiveness, distress to the child and preference of the responder.

We found that parents and nurses strongly disliked nasogastric rehydration. 30 out of 35 (86%) parents and 15 out of 17 (88%) nurses felt it was their least preferred method of rehydration. This compared to only 2 out of 11 (18%) doctors. Although it is an effective method of rehydration, there is therefore likely to be parent and nurse resistance to its use. If oral rehydration fails, intravenous rather than nasogastric rehydration will be chosen as the next step.

We suggest that the best way around this problem is to maximise the number of children in whom oral rehydration is successful. Thus, unit guidelines should emphasise that a serious attempt at oral rehydration is made in every child, giving specific advice about quantity of fluid in a specified time [1]. Parents should be given clear instructions, closely supervised and actively supported in oral rehydration.

We feel that time and energy spent on emphasising and showing the effectiveness of oral rehydration will prevent recourse to intravenous rehydration. There needs to be a culture change about nasogastric rehydration among parents and nurses before it is successfully used as a method of rehydration.

Dr. Tom P. Blyth, Paediatric Specialist Registrar

Dr. J J Rangasami, Consultant Paediatrician
West Middlesex University Hospital NHS Trust
Isleworth, Middlesex, UK

References:

(1) Armon K, Stephenson T, MacFaul R, et al. An evidence and consensus based guideline for acute diarrhoea management. Arch Dis Child 2001; 85:132-142.
(2) Murphy MS. Guidelines for managing acute gastroenteritis based on a systematic review of published research. Arch Disease Child 1998; 79:279- 284.
(3) American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice Parameter: The management of Acute Gastroenteritis in Young Children. Pediatrics 1996; 97:424-436.

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Re: Is antibiotic necessary in shigellosis?

We were interested to read Armon et al's[1] guidelines for acute diarrhoea management.The authors recommended that patients with Salmonella typhi, shigella, amoebiasis, and giardiasis should be treated with antibiotics. We wish to call attention again to antibiotic resistance in shigellosis. Shigella have become resistant to most antimicrobial agents used in its treatment[2,3]. In most developing countries, antibiotics are available without prescription, and there should be public awareness about the misuse of antibiotics. So the more antibiotics are used, the more resistance will increase. We have investigated drug resistance in shigella strains prospectively in a rural area near Ankara in 1988[4]. Comparison with results from the same region in 1981[5] show that the resistance to shigella had greatly increased. We wish to emphasize that antibiotics should be used mainly in severe shigella dysentery cases. Antibiotics should be used carefully in this disease because of the danger of antibiotic resistance.

I.SAFA KAYA*,MD Professor of Pediatrics
UĞUR DİLMEN*,MD Professor of Pediatrics
(*)Department of Pediatrics,

References:
(1) Armon K,Stephenson T,MacFaul R,et al.An evidence and consensus based guideline for acute diarrhoea management.Arch Dis Child 2001;85:132-142
(2) Kaya IS,Ceyhan M,Dilmen U,et al.Therapy for shigellosis.J Pediatr 1989;115:168
(3) Kaya IS,Dilmen U,Şenses DA.Danger of antibiotic resistance in shigellosis.Lancet 1990;ii:186
(4) Ceyhan M,Dilmen U,Korten V,Mert A.Shigella diarrhoea and treatment.Lancet 1988;ii:45-46
(5) Berkman E.The Serotypes and antibiotic resistance of shigella.Çocuk Sağl Hast Derg 1983;26:277-286

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Re: Rice oral rehydration solution may be used for rehydration of moderately dehydrated children

Dear Editor,

We have read with interest the article by Armon et al [1]. We would like to point out one of the important causes of treatment failure during WHO glucose-ORS treatment: transient glucose intolerance (TGI). In a recent case-control study about the clinical characteristics of transient glucose intolerance during acute diarrhea [2] it was found that TGI was most commonly seen in young children (median age 6 mo), with high stool frequency after the administration of WHO recommended glucose-ORS. Being non-breast fed was found to be another risk factor. WHO reccommends intravenous treatment for these cases but we have shown that these cases could be successfully managed by rice based ORS. The overall successs rate of rice-ORS (osmolarity 250mosm/L, containing 50 g/L instant rice powder with an equivalent electrolyte content to WHO glucose-ORS) treatment in cases with TGI was found to be 77.3% [3]. So we believe that even if a beneficial effect for rice-ORS in non-cholera cases has not been shown, rice-ORS should be kept in mind as an alternative treatment for TGI cases.

Elif Özmert, MD, PhD
Associate Professor of Pediatrics
Hacettepe University Faculty of Medicine
Department of Pediatrics, Social Pediatrics Unit
Ankar-TURKEY

Kadriye Yurdakök, MD
Professor of Pediatrics
Hacettepe University Institute of Child Health
Department of Social Pediatrics
Ankara Turkey

References
(1) Armon K, Stephenson T, MacFaul R, Eccleston P, Weneke U. An evidence and consensus based guidline for acute diarrhoea management. Arch Dis Child 2001;85:132-142.
(2) Özmert E, Yurdakök K, Aslan D, Yalçın SS, Yardım M. Clinical characteristics of transient glucose intolerance during acute diarrhea. Acta Paediatr 1999;88:1071-1073.
(3) Yurdakök K, Özmert E, Yalçın SS, Coşkun T. Rehydration of moderately dehydrated children with transient glucose intolerance using rice oral rehydration solution. Acta Paediatr 1999;88:34-37.