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BSPED guideline: what we know and why the guideline was changed
  1. Neil Wright1,
  2. Rum Thomas2
  1. 1 Paediatric Endocrinology and Diabetes, Sheffield Children's Hospital, Sheffield, UK
  2. 2 Paediatric Intensive Care Unit, Sheffield Children's Hospital, Sheffield, South Yorkshire, UK
  1. Correspondence to Dr Neil Wright, Paediatric Endocrinology & Diabetes, Sheffield Children's Hospital, Sheffield S10 2TH, UK; n.p.wright{at}

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Two key drivers underpinned the most controversial changes to the guideline—revised recommendations regarding fluids and an increased emphasis on treating shock. The first was the PECARN FLUID study (Pediatric Emergency Care Applied Research Network), a randomised controlled trial comparing a rapid with a slower rehydration fluid regimen.1 The second was concern, triggered by three deaths (unpublished audit data), that the fluid regime introduced in 2015 may be overly restrictive, increasing morbidity, and that anxiety about fluids may be inhibiting adequate resuscitation.

Cerebral oedema affects 1% of admissions with diabetic ketoacidosis (DKA). The traditional view that cerebral oedema is mediated by osmotic changes and may be precipitated or exacerbated by fluid administration has resulted in more restrictive fluid regimes.2 However, there is little evidence that such regimes have reduced the incidence of cerebral oedema.3–5 Evidence now suggests cerebral oedema results from initial cerebral hypoperfusion followed by a vasogenic or reperfusion injury.2 Cerebral oedema occurs at presentation, prior to any fluid administration, in up to 19% of cases.6 Asymptomatic subclinical cerebral oedema is evident in 50% of cases on MRI.7 Why some patients develop overt cerebral oedema remains unclear, and the role of fluids is contentious.

Of the six predominantly small case-control studies cited in the National Institute for Clinical Excellence (NICE) Guidance NG18 from which the previous 2015 British Society for Paediatric Endocrinology and Diabetes (BSPED) guideline evolved, four studies suggested that fluids were not a causal factor for cerebral oedema.5 6 8 9 The prospective UK case–control study, given the highest evidence rating, suggested higher fluid volumes may be a factor.10 However, the mean pH …

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  • Contributors NW and RT agreed a joint viewpoint. NW drafted the manuscript and both authors revised the original draft.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests NW and RT cochaired the task and finish British Society for Paediatric Endocrinology and Diabetes working group responsible for reviewing and revising the guidelines to produce the interim guidance.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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