A Commitment to Making Health Care Personal.

In this narrative medicine essay, an emergency medicine pediatrician describes the care his mother received in her last days and calls on the health care profession to aim for providing a personal touch when caring for patients.

When a Headache Is More than the Flu: A Case Report.

INTRODUCTION: When influenza (flu) season arrives, it is easy for emergency department clinicians to anchor on the diagnosis of flu, sending patients on their way with or without anti-influenza medication. It is important not to miss the outlier - the patient who seems to have typical symptoms of influenza but with certain subtleties that should make one consider expanding the differential diagnosis. CASE REPORT: We describe an 11-year-old previously healthy male who presented with eight days of fever, myalgias, cough, congestion, and headache in the context of positive influenza exposure. The length and severity of his symptoms prompted laboratory and imaging investigation. He was positive for influenza type B with elevated inflammatory markers but otherwise normal laboratory workup and normal chest radiograph. He complained of a headache and was given fluids and antipyretics, and was admitted for overnight observation. He specifically did not have any forehead swelling. The next day during his inpatient stay he developed right frontal forehead edema and appeared ill. He was taken for a sinus computed tomography, which showed changes consistent with frontal bone osteomyelitis. Even after drainage by neurosurgery and otolaryngology, the patient subsequently developed repeat abscesses and ultimately a superior sagittal sinus thrombosis. CONCLUSION: Other sources of infection should be considered in patients who have flu-like symptoms that last longer than expected, present with focality, or appear ill.

Seroprevalence of SARS-CoV-2 antibodies in front-line pediatric health care workers.

Objective: The goal of this study was to determine the prevalence of SARS-CoV-2 infections in pediatric front-line health care workers (HCWs) using SARS-CoV-2 serum antibodies as an indicator of infection. Methods: In this cross-sectional study, we collected blood samples and survey responses from HCWs in a 38-bed pediatric emergency department. Serum antibodies to SARS-CoV-2 (IgM and/or IgG) were measured using a 2-step enzyme-linked immunosorbent assay (ELISA) to detect antibodies against the Spike protein receptor binding domain (RBD), the ectodomain of Spike (S), and the nucleoprotein (N). Results: We collected survey responses and serum samples from 54 pediatric front-line HCWs from October 2020 through April 2021. Among the 29 unvaccinated HCWs, 4 (13.7%) had antibodies to SARS-CoV-2. For the 25 vaccinated HCWs, 10 (40%) were seropositive; 3 were <10 days from the first vaccine dose and 7 were ≥10 days after the first dose. Two of the 10 seropositive vaccines had a prior positive reverse transcription polymerase chain reaction test. Individuals ≥10 days from receiving the first vaccine dose were 37.5 (95% CI: 3.5-399.3) times more likely to have SARS-CoV-2 antibodies than unvaccinated individuals or those <10 days from first vaccine dose. Conclusions: Evidence of widespread SARS-CoV-2 infections was not found in unvaccinated front-line HCWs from a pediatric ED as of April 2021. Future work will be required to determine the reasons underlying the lower SARS-CoV-2 antibody prevalence compared to adult HCWs.

Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage: Identifying Low-Risk Patients Who May Not Benefit From ICU Admission.

BACKGROUND: Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary. OBJECTIVES: To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI). METHODS: We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI. RESULTS: Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6%; 95% confidence interval, 82.2%-99.9%) from the low-risk group, with a negative likelihood ratio of 0.056 (95% confidence interval, -0.053-0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55% of the sample). CONCLUSIONS: A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.

Performance characteristics of magnetic resonance imaging without contrast agents or sedation in pediatric appendicitis.

BACKGROUND: Magnetic resonance imaging (MRI) has emerged as a promising modality for evaluating pediatric appendicitis. However optimal imaging protocols, including roles of contrast agents and sedation, have not been established and diagnostic criteria have not been fully evaluated. OBJECTIVE: To investigate performance characteristics of rapid MRI without contrast agents or sedation in the diagnosis of pediatric appendicitis. MATERIALS AND METHODS: We included patients ages 4-18 years with suspicion of appendicitis who underwent rapid MRI between October 2013 and March 2015 without contrast agent or sedation. After two-radiologist review, we determined performance characteristics of individual diagnostic criteria and aggregate diagnostic criteria by comparing MRI results to clinical outcomes. We used receiver operating characteristic (ROC) curves to determine cut-points for appendiceal diameter and wall thickness for optimization of predictive power, and we calculated area under the curve (AUC) as a measure of test accuracy. RESULTS: Ninety-eight MRI examinations were performed in 97 subjects. Overall, MRI had a 94% sensitivity, 95% specificity, 91% positive predictive value and 97% negative predictive value. Optimal cut-points for appendiceal diameter and wall thickness were ≥7 mm and ≥2 mm, respectively. Independently, those cut-points produced sensitivities of 91% and 84% and specificities of 84% and 43%. Presence of intraluminal fluid (30/33) or localized periappendiceal fluid (32/33) showed a significant association with acute appendicitis (P<0.01), with sensitivities of 91% and 97% and specificities of 60% and 50%. For examinations in which the appendix was not identified by one or both reviewers (23/98), the clinical outcome was negative. CONCLUSION: Rapid MRI without contrast agents or sedation is accurate for diagnosis of pediatric appendicitis when multiple diagnostic criteria are considered in aggregate. Individual diagnostic criteria including optimized cut-points of ≥7 mm for diameter and ≥2 mm for wall thickness demonstrate high sensitivities but relatively low specificities. Nonvisualization of the appendix favors a negative diagnosis.

Impact of an Inpatient Psychiatric Unit on Pediatric Emergency Mental Health Care.

OBJECTIVES: Mental health complaints are a frequent presentation to the pediatric emergency department (PED). It is unclear if having an on-site inpatient pediatric psychiatric unit impacts pediatric mental health care in the acute setting. The objective of this study was to compare PED mental health care between a pediatric tertiary care center with an associated inpatient child psychiatric unit (PAPED) and one that does not (NOPED) with the hypothesis that children have longer lengths of stay (LOS) at the PED without an inpatient unit. METHODS: This was a retrospective, observational study of all mental health presentations aged 1 to 18 years to 2 tertiary care PEDs from March 2012 to June 2013 with a final mental health diagnosis International Classification of Diseases, Ninth Revision code. RESULTS: A total of 1409 patient encounters comprised the study group. The PAPED had a significantly higher rate of admission 41.3% versus 18.8% (P < 0.0001). The LOS was significantly longer at the NOPED compared with the PAPED with a visit of 15.6 versus 6.3, respectively (P < 0.0001). When LOS was stratified for disposition, patients requiring admission from the NOPED had a significantly longer LOS of 33.4 compared with an emergency department LOS of 8.1 at the PAPED (P < 0.0001). CONCLUSIONS: Mental health care in the PED seems to be affected by having an associated inpatient child psychiatric unit. Further research needs to address this growing problem and ways to utilize community resources to develop safe outpatient plans and divert admission if possible.

A randomized trial of Plasma-Lyte A and 0.9 % sodium chloride in acute pediatric gastroenteritis.

BACKGROUND: Compare the efficacy and safety of Plasma-Lyte A (PLA) versus 0.9 % sodium chloride (NaCl) intravenous (IV) fluid replacement in children with moderate to severe dehydration secondary to acute gastroenteritis (AGE). METHODS: Prospective, randomized, double-blind study conducted at eight pediatric emergency departments (EDs) in the US and Canada (NCT#01234883). The primary outcome measure was serum bicarbonate level at 4 h. Secondary outcomes included safety and tolerability. The hypothesis was that PLA would be superior to 0.9 % NaCl in improvement of 4-h bicarbonate. Patients (n = 100) aged ≥6 months to <11 years with AGE-induced moderate-to-severe dehydration were enrolled. Patients with a baseline bicarbonate level ≤22 mEq/L formed the modified intent to treat (mITT) group. RESULTS: At baseline, the treatment groups were comparable except that the PLA group was older. At hour 4, the PLA group had greater increases in serum bicarbonate from baseline than did the 0.9 % NaCl group (mean ± SD at 4 h: 18 ± 3.74 vs 18.0 ± 3.67; change from baseline of 1.6 and 0.0, respectively; P = .004). Both treatment groups received similar fluid volumes. The PLA group had less abdominal pain and better dehydration scores at hour 2 (both P = .03) but not at hour 4 (P = 0.15 and 0.08, respectively). No patient experienced clinically relevant worsening of laboratory findings or physical examination, and hospital admission rates were similar. One patient in each treatment group developed hyponatremia. Four patients developed hyperkalemia (PLA:1, 0.9 % NaCl:3). CONCLUSION: In comparison with 0.9 % NaCl, PLA for rehydration in children with AGE was well tolerated and led to more rapid improvement in serum bicarbonate and dehydration score. TRIAL REGISTRATION: NCT#01234883 (Registration Date: November 3, 2010).

Mental Health Utilization in a Pediatric Emergency Department.

OBJECTIVE: Mental health complaints are frequent in the pediatric emergency department (PED). The objective of this study was to describe trends over time in PED utilization for mental health care at in a single pediatric tertiary care hospital. It is our hypothesis that the resources used by this patient population are high and that mental health-related visits have increased over the most recent decade. METHODS: This was a retrospective study of all pediatric mental health presentations to the PED from January 2009 to July 2013 at a single pediatric hospital. All patients aged 1 to 19 years with an International Classification of Diseases, Ninth Revision code of 291, 292, 295 to 309, and 311 to 314 were included. Data collected included demographic data, medications received, restraint use, suicidality, length of stay (LOS), charges incurred, final disposition, and daily PED operation variables. Trends over time in presentation, charges, and LOS were analyzed using multiple mixed effects regression models after adjusting for potential patient and PED level confounding variables and clustering of multiple visits within patients. RESULTS: A total of 732 PED visits from 2009 to 2013 were identified representing 646 unique patients. The average age was 13.8 years, and 53% were male. Approximately 25% of the patients expressed suicidal ideation, and 44% of those had attempted suicide before arrival. Behavioral or chemical restraints were used in 33% of patients during their PED visit. There were statistically significant increases in annual visits, LOS, and charges over this period (P < 0.05). Increased charges were significantly associated with longer LOS (P = 0.0062). Charges (P = 0.46) and LOS (P = 0.62) were not significantly different between suicidal and nonsuicidal patients. Approximately 21% of patients were admitted or transferred to another facility. CONCLUSIONS: In this single-center study, we found evidence that the resources required to care for pediatric patients with mental health complaints have increased significantly over time both by increased number of annual visits and an increasing LOS. Further research is necessary to determine if our data are consistent with national trends to further our understanding of the problem and improve resource allocation.

Test characteristics of quick brain MRI for shunt evaluation in children: an alternative modality to avoid radiation.

OBJECT: Quick brain magnetic resonance imaging (QB-MRI) is a rapid, radiation-free technique to detect life-threatening CSF shunt malfunction. QB-MRI has not been widely studied or adopted. The primary objective of this study was to evaluate the test characteristics of QB-MRI for detecting shunt malfunction. Test characteristics of brain computed tomography (CT) and QB-MRI were then compared. Secondary objectives included comparison of time to study completion and use of sedatives for both modalities, as well as comparison of time to study completion for QB-MRI before and after implementation of a Pediatric Emergency Department (PED) shunt clinical pathway. METHODS: A retrospective chart review was performed at 2 tertiary care hospital PEDs. The authors reviewed the charts of children who underwent QB-MRI or CT for suspected shunt malfunction between July 2008 and June 2012. They also reviewed the patients' neuroradiology reports and classified ventricular size as positive (enlarged) or negative (normal, smaller, or unchanged). Shunt malfunction was defined by surgical revision within 30 days. RESULTS: Nine hundred ninety-seven PED visits (involving 724 QB-MRIs and 273 CTs) were included. Surgical revision was performed in 235 cases (23.6%). For QB-MRI, sensitivity was 58.5% (95% CI 51.1%-65.6%) and specificity was 93.3% (90.8%-95.3%). For CT, sensitivity was 53.2% (95% CI 38.1%-67.9%) and specificity was 95.6% (92%-97.9%). The mean time to completion of QB-MRI was 115 minutes versus 83 minutes for CT (difference 32 minutes, 95% CI, 22-42 minutes, p < 0.001). The mean time from presentation to completion of QB-MRI prior to application of the CSF shunt pathway was 132 minutes versus 112 minutes after application of the CSF shunt pathway (difference 20 minutes, 95% CI 5-35 minutes, p = 0.01). Anxiolytic medications were used in 3.7% of CT studies and 4.4% of QB-MRI studies (p = 0.74). CONCLUSIONS: QB-MRI and CT have similar test characteristics for detecting CSF shunt malfunction in children and similar requirements for sedation. The longer interval from order placement to imaging completion for QB-MRI is arguably justified by reduction of radiation exposure in this population subject to frequent brain imaging.

Pediatric migraine: abortive management in the emergency department.

Studies suggest that headache accounts for approximately 1% of pediatric emergency department (ED) visits. ED physicians must distinguish between primary headaches, such as a tension or migraine, and secondary headaches caused by systemic disease including neoplasm, infection, or intracranial hemorrhage. A recent study found that 40% of children presenting to the ED with headache were diagnosed with a primary headache, and 75% of these were migraine. Once the diagnosis of migraine has been made, the ED physician is faced with the challenge of determining appropriate abortive treatment. This review summarizes the most recent literature on pediatric migraine with an emphasis on diagnosis and abortive treatment in the ED.

Evaluation of a novel pediatric appendicitis pathway using high- and low-risk scoring systems.

OBJECTIVES: This study aimed to determine the test characteristics of a pathway for pediatric appendicitis and its effects on emergency department (ED) length of stay, imaging, and admissions. METHODS: Children age 3 to 18 years with suspicion for appendicitis at 1 tertiary care ED were prospectively enrolled, using validated low- and high-risk scoring systems incorporating history, physical examination, and white blood cell count. Low-risk patients were discharged or observed in the ED. High-risk patients were admitted. Those meeting neither low-risk nor high-risk criteria were evaluated by surgery, with imaging at their discretion. Chart review or telephone follow-up was conducted 2 weeks after the visit. A retrospective study before and after was also performed. Charts of a random sample of patients evaluated for appendicitis in the 8 months before and after the pathway implementation were reviewed. RESULTS: Appendicitis was diagnosed in 65 of 178 patients. Of those with appendicitis, 63 were not low-risk (sensitivity, 96.9%; specificity, 40.7%). The high-risk criteria had a sensitivity of 75.3% and specificity of 75.2%. We reviewed 292 visits before and 290 after the pathway implementation. Emergency department length of stay was similar (253 minutes before vs 257 minutes after, P = 0.77). Computed tomography was used in 12.7% of visits before and 6.9% of visits after (P = 0.02). Use of ultrasound was not significantly different (47.3% vs 53.7%). Admission rates were not significantly different (45.5% vs 42.7%). CONCLUSIONS: The low-risk criteria had good sensitivity in ruling out appendicitis. The high-risk criteria could be used to guide referral or admission. Neither outperformed the a priori judgment of experienced providers.

Diagnostic testing and treatment of pediatric headache in the emergency department.

OBJECTIVE: To describe the variability in diagnostic testing and treatment of headaches in children presenting to the emergency department (ED) with use of a nationally representative sample. STUDY DESIGN: This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey during 2005-2009. To assess the use of evidence-based treatment, we analyzed all patients <18 years old in 2 groups: (1) primary discharge diagnosis of headache and (2) discharge diagnosis of migraine. RESULTS: Four hundred forty-eight sampled ED visits from 2005-2009 represented a national estimate of 1.7 million visits with a discharge diagnosis of headache. A total of 95 visits represented a national estimate of 340 000 visits with a discharge diagnosis of migraine. Median age was 13.1 years and 60% were female with a primary diagnosis of headache. In this group, neuroimaging was performed in 37% of patients and 39% underwent blood tests. Nonsteroidal anti-inflammatory drugs and opioids were most commonly used for treatment. For children with a discharge diagnosis of migraine, approximately 40% of patients received non-evidence-based treatment, most commonly with opioid medications, and >20% of patients underwent computed tomography scanning. CONCLUSIONS: There is significant variability in the evaluation and treatment of pediatric headache in the ED. Despite evidence-based clinical guidelines for migraine headache, a large number of children continue to receive opioids and ionizing radiation in the ED.

A novel biomarker panel to rule out acute appendicitis in pediatric patients with abdominal pain.

OBJECTIVES: To identify a biomarker panel with sufficient sensitivity and negative predictive value to identify children with abdominal pain at low risk for acute appendicitis in order to avoid unnecessary imaging. METHODS: We prospectively enrolled 503 subjects aged two to 20 years with <72 hours of abdominal pain consistent with appendicitis. Blood samples from each patient were analyzed for CBC, differential, and 5 candidate proteins. Biomarker values were evaluated using principal component, recursive partitioning and logistic regression to select the combination that best discriminated between those subjects with and without disease. RESULTS: The prevalence of acute appendicitis was 28.6%. A mathematical combination of three inflammation-related markers in a panel comprised of white blood cell count (WBC), C-reactive protein (CRP), and myeloid-related protein 8/14 complex (MRP 8/14) provided the best discrimination. This panel exhibited a sensitivity of 96.5% (95% CI, 92-99%), a negative predictive value of 96.9% (95% CI, 93-99%), a negative likelihood ratio of 0.08 (95% CI, 0.03- 0.19), and a specificity of 43.2% (95% CI, 38-48%) for acute appendicitis. Sixty of 185 CT scans (32.4%) were done for patients with negative biomarker panel results which, if deferred, would have reduced CT utilization at initial presentation by one third at the cost of missing five of 144 (3.5%) patients with appendicitis. CONCLUSION: This panel may be useful in identifying pediatric patients with signs and symptoms suggestive of acute appendicitis who are at low risk and can be followed clinically, potentially sparing them exposure to the ionizing radiation of CT.

Bedside optic nerve sheath diameter ultrasound for the evaluation of suspected pediatric ventriculoperitoneal shunt failure in the emergency department.

OBJECTIVE: To determine the feasibility and test characteristics of optic nerve sheath diameter (ONSD) measured by ocular ultrasound as a screening tool for ventriculoperitoneal shunt (VPS) failure. METHODS: Prospective observational study using a convenience sample of children 6 months to 18 years of age, presenting to an academic pediatric emergency department for evaluation of possible VPS failure between September 2008 and March 2009. ONSD was measured by anterior transbulbar and lateral transbulbar techniques. Mean ONSD was compared between subjects with and without shunt failure, as determined by neurosurgical decision to operate. RESULTS: A total of 39 encounters were completed, including 20 VPS failures. The mean ONSD was 4.5 ± 0.9 and 5.0 ± 0.6 mm among encounters with and without shunt failure (p = 0.03), respectively. The mean ONSD was not statistically different when obtained by the anterior transbulbar vs. the lateral transbulbar approach (4.8 ± 1.0 vs. 4.7 ± 0.8 mm, p = 0.12). ONSD ultrasound had a sensitivity of 61.1 % (95 % CI 35.7-82.7) and specificity of 22.2 % (95 % CI 6.4-47.6 %) for detecting shunt failure in this sample. CONCLUSIONS: ONSD ultrasound does not appear to be a useful primary screening tool in emergency department evaluation of VPS failure. There was no difference between the anterior transbulbar approach and the lateral transbulbar approach. Children with VPS in our sample have larger ONSD measurements than in previously reported studies.

Overweight physicians during residency: a cross-sectional and longitudinal study.

BACKGROUND: Resident physicians are at risk for increasing weight status given their changes in environment, resources, and stress level. OBJECTIVE: To describe body mass index (BMI), blood pressure, eating habits, and physical activity during postgraduate training and to compare the findings to data for nationally matched controls. METHODS: This was a combined cross-sectional study and longitudinal cohort, with a comparison to matched controls in 2 academic hospital centers in the eastern and western United States. BMI and blood pressure were objectively measured, and an eating and exercise habits recall was obtained for 375 enrolled medical and surgical residents (93 longitudinally) at the onset of each postgraduate year (PGY) in 2006, 2007, and 2008. RESULTS: Nearly half (43%) of overweight residents described themselves as normal weight. Residents were more likely to be overweight (BMI ≥25) at the beginning of PGY-3 than at the beginning of PGY-1 (49% versus 30%; odds ratio 2.26; 95% confidence interval 1.19-4.28). The average BMI of residents at PGY-1 was lower than that of their matched controls, but the magnitude of this difference decreased with increasing PGY (P  =  .02). CONCLUSIONS: Overweight status is underacknowledged by overweight residents and increases by PGY of training. These changes differ significantly from that of controls and may affect overweight physicians' long-term health.

Low-dose propofol for the abortive treatment of pediatric migraine in the emergency department.

OBJECTIVE: Limited progress has been made in the past decade for abortive treatment of migraine headache in the pediatric emergency department (PED). Propofol, a general anesthetic, has been reported to be effective in the treatment of refractory headaches in adults at subanesthetic doses but never in the pediatric population. The goal of this study was to review our institution's experience with subanesthetic doses of propofol for the abortive treatment of pediatric migraine and compare propofol with standard abortive therapy in the PED. METHODS: Retrospective review of all patients discharged from the Oregon Health and Science University PED with a diagnosis of migraine headache from January 2010 to July 2011. Patients treated with subanesthetic doses of propofol were compared with matched controls who received standard abortive migraine therapy, defined as the combined use of a nonsteroidal anti-inflammatory medication, diphenhydramine, and prochlorperazine. Outcome variables of interest included reduction of pain as measured on a self-reported visual analog scale and length of stay after administration of initial abortive medication. RESULTS: Patients who received subanesthetic doses of propofol achieved significantly greater reduction in pain scores (80.1% vs 61.1%; P < 0.05) compared with matched controls as well as shorter stay (122 minutes vs 203 minutes; P = 0.2) after treatment. No adverse effects (hypotension, respiratory depression, or hypoxia) were recorded in either group. CONCLUSIONS: Propofol seems to be effective for the abortive treatment of pediatric migraine headache in the PED. Further prospective trials are warranted to either support or refute these initial findings.

A randomized clinical trial of recombinant human hyaluronidase-facilitated subcutaneous versus intravenous rehydration in mild to moderately dehydrated children in the emergency department.

BACKGROUND: Alternative treatment of dehydration is needed when intravenous (IV) or oral rehydration therapy fails. Subcutaneous (SC) hydration facilitated by recombinant human hyaluronidase offers an alternative treatment for dehydration. This clinical trial is the first to compare recombinant human hyaluronidase-facilitated SC (rHFSC) rehydration with standard IV rehydration for use in dehydrated children. OBJECTIVE: This Phase IV noninferiority trial evaluated whether rHFSC fluid administration can be given safely and effectively, with volumes similar to those delivered intravenously, to children who have mild to moderate dehydration. METHODS: The study included mild to moderately dehydrated children (Gorelick dehydration score) aged 1 month to 10 years. They were randomized to receive 20 mL/kg of isotonic fluids using rHFSC or IV therapy over 1 hour and then as needed until clinically rehydrated. The primary outcome was total volume of fluid administered (emergency department [ED] plus inpatient hospitalization). Secondary outcomes included mean volume infused in the ED alone, postinfusion dehydration scores and weight changes, line placement success and time, safety, and provider and parent/guardian questionnaire. RESULTS: 148 patients (mean age, 2.3 [1.91] years]; white, 53.4%; black, 31.8%) were enrolled in the intention-to-treat population (73 rHFSC; 75 IV). The primary outcome, mean total volume infused, was 365.0 (324.6) mL in the rHFSC group over 3.1 hours versus 455.8 (597.4) mL in the IV group over 6.6 hours (P = 0.51). The secondary outcome of mean volume infused in the ED alone was 334.3 (226.40) mL in the rHFSC group versus 299.6 (252.33) mL in the IV group (P = 0.03). Dehydration scores and weight changes postinfusion were similar. Successful line placement occurred in all 73 rHFSC-treated patients and 59 of 75 (78.7%) IV-treated patients (P < 0.0001). All IV failures occurred in patients aged <3 years; rHFSC rescue was successful in all patients in whom it was attempted. Both treatments were well tolerated. Clinicians rated fluid administration as easy to perform in 94.5% (69 of 73) of the rHFSC group versus 65.3% (49 of 75) of the IV group (P < 0.001). Parents/caregivers were satisfied or very satisfied with fluid administration in 94.5% (69 of 73) of rHFSC-treated patients and 73.3% (55 of 75) of IV-treated patients. CONCLUSIONS: In mild to moderately dehydrated children, rHFSC was inferior to IV hydration for the primary outcome measure. However, rHFSC was noninferior in the ED phase of hydration. Additional benefits of rHFSC included time and success of line placement, ease of use, and satisfaction. SC hydration facilitated with recombinant human hyaluronidase represents a reasonable addition to the treatment options for children who have mild to moderate dehydration, especially those with difficult IV access. ClinicalTrials.gov identifier: NCT00773175.