Copyright 2013 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. Emergency Department Revisits in Children With Gastroenteritis  Stephen B. Freedman, y Jennifer D. Thull-Freedman, z Maggie Rumantir, § Eshetu G. Atenafu, and jj Derek Stephens ABSTRACT Objectives: The aim of the study was to determine whether intravenous fluid administration is independently associated with a reduction in unscheduled emergency department (ED) revisits within 7 days. Methods: We conducted a single-center, retrospective observational cohort study in a pediatric ED in Toronto, Canada. Participants were younger than 18 years, diagnosed as having gastroenteritis, and discharged home between July 2003 and June 2008. Multivariable regression models were used to determine the associations between the exposures (intravenous rehydration, triage severity score, age) and ED revisits and revisits with intravenous rehydration. Accuracy was assessed using bootstrap analysis. Results: There were 22,125 potentially eligible visits; 3346 were included in our final cohort. A total of 497 children (15%) received intravenous rehydration and 543 (16%) had an unscheduled revisit. Regression analysis included 2874 children with complete data, and identified 5 independent predictors of an ED revisit: intravenous rehydration (odds ratio [OR] 1.76; 95% confidence interval [CI] 1.36–2.26); number of vomiting episodes (1.20; 95% CI 1.04–1.28/5 episode increase); days of diarrhea (OR 0.92; 95% CI 0.88–0.97/day increase); frequency of diarrhea (1.19; 95% CI 1.03–1.38/5 episode increase); and age (OR 0.94; 95% CI 0.91–0.98/year). Bootstrap methodology identified intravenous rehydration, age, number of vomiting episodes, days of diarrhea, and number of diarrheal stools a minimum of 500 of 1000 iterations. Conclusions: Intravenous rehydration is associated with unscheduled ED revisits after adjustment for clinical findings. Although children experiencing revisits were likely more unwell, our data do not support the provision of intravenous fluids to prevent unscheduled ED revisits in children with mild-to-moderate dehydration. Key Words: ambulatory care facilities, dehydration, emergencies, emergency department, gastroenteritis, intravenous infusions, pediatric (JPGN 2013;57: 612–618) M ore than 1.7 million children with acute gastroenteritis present for emergency department (ED) care annually in the United States (1). Gastroenteritis treatment regimens have been outlined in guidelines endorsed by the American Academy of Pediatrics (2). A fundamental principle included in these guidelines is the administration of oral rehydration therapy (ORT) to the vast majority of children with gastroenteritis; however, surveys have shown that a gap exists between guide- lines and practice (3). Numerous justifications are provided to explain the over- reliance on intravenous rehydration. These include vomiting— physicians are more likely to use intravenous therapy when vomiting is the major symptom (4); familiarity—unfamiliarity with ORT techniques and a comfort with intravenous rehydration; beliefs— that intravenous rehydration is faster and decreases the length of hospital stay (5,6); expectations—of the family and by the referring physician (5,7); culture—health care providers are trained to not miss a significant illness which leads to overtesting and treating (8); and technology—the use of a more modern approach is favored by many caregivers (9). Although intravenous rehydration can reverse the presence of dehydration at the time of ED presentation, there is limited evidence describing the relation between intravenous rehy- dration and outcomes following ED discharge; however, because 75% of unscheduled pediatric ED revisits are because symptoms persist or get worse (10), a better understanding of this relation is warranted. Given that intravenous rehydration does not reduce symp- toms following discharge (11), we hypothesized that unscheduled revisits are not reduced by the administration of intravenous rehydration. Our primary objective was to determine whether intravenous fluid administration to children treated in an ED and discharged is independently associated with a reduction in unsched- uled ED revisits within the subsequent 7 days. Received February 5, 2013; accepted June 17, 2013. From the  Sections of Pediatric Emergency Medicine, the y Gastroentero- logy, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, the z Divisions of Paediatric Emergency Medicine and Child Health Evaluative Sciences, The Hospital for Sick Children, the § Biostatistics Department, University Health Network, and the jj Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada. Address correspondence and reprint requests to Stephen B. Freedman, MDCM, MSc, Divisions of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary, Alberta T3B 6A8, Canada (e-mail: stephen.freedma- n@albertahealthservices.ca). Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jpgn.org). This study was presented at the 2012 Pediatric Academic Society Annual Meeting, April 30, 2012 in Boston, MA. A study reporting on the same group of patients was published in JPGN in 2012 (54:381–6. Because of the vastly different emphasis of the other article, the data that they contain could not be combined into a single manuscript. This work was financially supported by the Division of Pediatric Emergency Medicine, The Hospital for Sick Children. The study sponsors played no role in study design or data collection, analysis, and interpretation or in the writing of the article and the decision to submit it for publication; all researcher activities were independent of the funding source; and the research team had full and unrestricted access to all the data. S.B.F. is conducting a study using study product (ondansetron/placebo) from GlaxoSmithKline. The other authors report no conflicts of interest. Copyright # 2013 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0b013e3182a1dd93 ORIGINAL ARTICLE:GASTROENTEROLOGY 612 JPGN  Volume 57, Number 5, November 2013