Scientific Letter
Home monitoring of sodium in children with adipsic diabetes insipidus
Monitorización domiciliaria de sodio en niños con diabetes insípida y adipsia
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On one hand, they are at risk of hyponatraemia resulting from excessive fluid intake due to absolute or relative overdosage of desmopressin. On the other hand, due to the absence of thirst, they are also at risk of hypernatraemia due to fluid deprivation if lost fluids are not properly replenished.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the cases of 3 children with panhypopituitarism with antidiuretic hormone deficiency (central diabetes insipidus) and adipsia as immediate complications of surgical removal of large hypothalamic tumours. After a protracted postoperative hospital stay due to countless episodes of hyponatraemia and hypernatraemia, patients could be discharged home and managed at the outpatient level by providing parents with a portable system for measuring capillary blood sodium levels at home.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patients were 2 girls and 1 boy aged 5.5, 15 and 9 years, respectively, that had undergone surgery for treatment of craniopharyngioma, optic nerve glioma and mixed germ cell tumour and were hospitalised for 96, 105 and 53 days (42, 9 and 23 of these days in the intensive care unit). The complications from abnormal sodium levels in these patients included status epilepticus and cerebral oedema secondary to hyponatraemia in the 2 younger patients and thromboembolic disease secondary to hypernatraemia in the adolescent patient.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We provided parents with a portable blood analysis device (EPOC point-of-care blood analysis system; Epocal Inc, Ottawa, Canada) that has been validated for measurement of capillary blood sodium concentrations on account of the good correlation of these measurements with those obtained by benchtop methods.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The system requires 92<span class="elsevierStyleHsp" style=""></span>μL of capillary blood per test and provides results in 3.5<span class="elsevierStyleHsp" style=""></span>min, with an approximate cost of 5 euro per measurement. The device is portable, as it weighs only 680<span class="elsevierStyleHsp" style=""></span>g, and can perform 50 measurements on one battery charge. We held a training session for parents and primary care providers (paediatricians and nurses) on the use of this system, and during the hospital stay we trained parents on how to collect capillary blood samples, on the management protocol and how to respond to abnormal sodium levels. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the contents of the printout of recommendations given at discharge. Families were informed that they could contact the clinic by telephone between 13:30 and 15:00 pm on weekdays.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The 3 families assumed the responsibility to monitor serum sodium levels at home, which they preferred over visiting a health care centre or laboratory. The patients have returned to school and leisure activities, and parents have returned to work. At the time of this writing, the duration of at-home follow-up in the 3 patients has been of 20, 10 and 7 months, with a follow-up visit at our clinic every 3 months. In this interval, they have needed to visit the emergency department 6 times for reasons related to their sodium levels (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), leading to short hospitalizations (<48<span class="elsevierStyleHsp" style=""></span>h), except in one case in which hypernatraemia triggered acute kidney injury, which prolonged the hospital stay to 14 days.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Home monitoring of capillary blood sodium levels is a rare practice, with barely half a dozen of children using this approach reported in the current international literature, but this measure is completely accepted by its users.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4–6</span></a> With its implementation, we are taking another step to increase patient safety, family quality of life and, ultimately, to make paediatrics practice more humane. The use of home serum sodium monitoring could facilitate patient discharge, reduce the frequency of readmissions and the associated lengths of stay, reduce the number of visits to health care centres, allow an earlier return to school, work and leisure activities and open more time for children to enjoy their childhoods. A structured educational programme is essential in this approach to facilitate adherence to treatment by the family and good communication between health professionals (nurse-paediatrician) and between levels of care (primary care-hospital-based care).</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Peinado Barraso MC, García García E. Monitorización domiciliaria de sodio en niños con diabetes insípida y adipsia. An Pediatr (Barc). 2020;93:262–264.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">DP, desmopressin; IV, intravenous.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Prevention of hypernatraemia</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Administer a fixed amount of fluids daily to cover baseline needs and immediately replenish fluid losses of any kind, including</span>: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Polyuria: replenish the volume in excess of the usual urine volume \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Insensible losses (heat, fever, physical activity or tachypnoea), gastrointestinal losses (diarrhoea, vomiting) or other fluid losses (haemorrhage, effusion, etc) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Prevention of hyponatraemia</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Before administering DP, wait for the effects of the previous dose to be done (abundant and clear urine)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Avoid excessive fluid intake</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Serum sodium measurements</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Regular measurements (every 1, 2 or 3 days, depending on stability of patient), plus measurement in the event of any disease or symptom</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Acceptable values in these children range from 138 to 148</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mEq/L</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Sodium <138</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">mEq/L (hyponatraemia or level in the lower limit of normal)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">In case of mild symptoms (nausea, vomiting, headache) or no symptoms</span>: <span class="elsevierStyleItalic">restrict fluids and wait for urine to be abundant and clear before administering another dose of DP. Reduce total daily fluid intake by 5%</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">In case of severe symptoms (confusion, respiratory distress, coma, seizures, apnoea)</span>: <span class="elsevierStyleItalic">alert the emergency department to prepare administration of IV hypertonic saline solution</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Sodium >148</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">mEq/L (significant hypernatraemia)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">In case of no symptoms or mild symptoms (irritability)</span>: <span class="elsevierStyleItalic">replenish dehydration losses properly and increase the total daily fluid intake by 5%</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">In case of severe symptoms (hypertonia, hyperreflexia, decreased level of consciousness)</span>: <span class="elsevierStyleItalic">contact emergency department and bring patient for IV rehydration</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2614028.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Printout of recommendations given to parents for home-based care after hospital discharge.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient (age) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reason \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Serum sodium (mEq/L) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Length of stay \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (5.5 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Convulsive seizures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">139 (previous, 155) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (5.5 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Status epilepticus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">126 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (5.5 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Convulsive seizures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">132 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (9 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Confusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">132 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (15 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Confusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">170 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (15 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever and difficulty eating \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">157 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2614029.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Emergency department visits during home-based follow-up after hospital discharge with home monitoring of capillary blood sodium levels.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of diabetes insipidus and adipsia in the child" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "N. Di Iorgi" 1 => "G. Morana" 2 => "F. Napoli" 3 => "A.E. Allegri" 4 => "A. Rossi" 5 => "M. Maghnie" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.beem.2015.04.013" "Revista" => array:6 [ "tituloSerie" => "Best Pract Res Clin Endocrinol Metab" "fecha" => "2015" "volumen" => "29" "paginaInicial" => "415" "paginaFinal" => "436" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26051300" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current best practice in the management of patients after pituitary surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Prete" 1 => "S.M. Corsello" 2 => "R. 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Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajem.2017.12.025" "Revista" => array:7 [ "tituloSerie" => "Am J Emerg Med" "fecha" => "2018" "volumen" => "36" "paginaInicial" => "1215" "paginaFinal" => "1221" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29519760" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0268960X15000569" "estado" => "S300" "issn" => "0268960X" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "For debate: Personalized health care: as exemplified by home sodium measurements in a child with central diabetes insipidus and impaired thirst perception" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.A.A. Van der Linde" 1 => "A.E. van Herwaarden" 2 => "J.D. Oosting" 3 => "H.L. Claahsen-van der Grinten" 4 => "E.P.L.M. de Grouw" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.17458/per.vol15.2018.lho.fd.CentralDiabetesInsipidus" "Revista" => array:6 [ "tituloSerie" => "Pediatr Endocrinol Rev" "fecha" => "2018" "volumen" => "15" "paginaInicial" => "276" "paginaFinal" => "279" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29806747" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Home blood sodium monitoring, sliding-scale fluid prescription and subcutaneous DDAVP for infantile diabetes insipidus with impaired thirst mechanism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Hameed" 1 => "A.C. Mendoza-Cruz" 2 => "K.A. Neville" 3 => "H.J. Woodhead" 4 => "J.L. Walker" 5 => "C.F. 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Landt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1067/mpd.2002.128544" "Revista" => array:6 [ "tituloSerie" => "J Pediatr" "fecha" => "2002" "volumen" => "141" "paginaInicial" => "618" "paginaFinal" => "624" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12410188" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000009300000004/v2_202106040604/S234128792030140X/v2_202106040604/en/main.assets" "Apartado" => array:4 [ "identificador" => "38181" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000009300000004/v2_202106040604/S234128792030140X/v2_202106040604/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234128792030140X?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
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| 2024 November | 3 | 5 | 8 |
| 2024 October | 41 | 42 | 83 |
| 2024 September | 55 | 64 | 119 |
| 2024 August | 75 | 68 | 143 |
| 2024 July | 72 | 30 | 102 |
| 2024 June | 58 | 17 | 75 |
| 2024 May | 73 | 28 | 101 |
| 2024 April | 49 | 33 | 82 |
| 2024 March | 40 | 23 | 63 |
| 2024 February | 48 | 30 | 78 |
| 2024 January | 51 | 20 | 71 |
| 2023 December | 35 | 25 | 60 |
| 2023 November | 62 | 41 | 103 |
| 2023 October | 53 | 25 | 78 |
| 2023 September | 58 | 30 | 88 |
| 2023 August | 49 | 20 | 69 |
| 2023 July | 54 | 25 | 79 |
| 2023 June | 54 | 28 | 82 |
| 2023 May | 69 | 22 | 91 |
| 2023 April | 53 | 12 | 65 |
| 2023 March | 62 | 35 | 97 |
| 2023 February | 60 | 22 | 82 |
| 2023 January | 47 | 24 | 71 |
| 2022 December | 111 | 29 | 140 |
| 2022 November | 98 | 39 | 137 |
| 2022 October | 82 | 53 | 135 |
| 2022 September | 64 | 37 | 101 |
| 2022 August | 127 | 44 | 171 |
| 2022 July | 85 | 56 | 141 |
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| 2022 May | 89 | 39 | 128 |
| 2022 April | 71 | 36 | 107 |
| 2022 March | 74 | 59 | 133 |
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| 2022 January | 58 | 28 | 86 |
| 2021 December | 41 | 42 | 83 |
| 2021 November | 46 | 41 | 87 |
| 2021 October | 60 | 76 | 136 |
| 2021 September | 42 | 48 | 90 |
| 2021 August | 34 | 43 | 77 |
| 2021 July | 40 | 24 | 64 |
| 2021 June | 57 | 45 | 102 |
| 2021 May | 44 | 39 | 83 |
| 2021 April | 151 | 94 | 245 |
| 2021 March | 70 | 39 | 109 |
| 2021 February | 85 | 35 | 120 |
| 2021 January | 68 | 23 | 91 |
| 2020 December | 79 | 34 | 113 |
| 2020 November | 50 | 18 | 68 |
| 2020 October | 43 | 15 | 58 |
| 2020 September | 49 | 33 | 82 |
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