External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study

Abstract

Summary Background Dehydration due to diarrhoea is a leading cause of child death worldwide, yet no clinical tools for assessing dehydration have been validated in resource-limited settings. The Dehydration: Assessing Kids Accurately (DHAKA) score was derived for assessing dehydration in children with diarrhoea in a low-income country setting. In this study, we aimed to externally validate the DHAKA score in a new population of children and compare its accuracy and reliability to the current Integrated Management of Childhood Illness (IMCI) algorithm. Methods DHAKA was a prospective cohort study done in children younger than 60 months presenting to the International Centre for Diarrhoeal Disease Research, Bangladesh, with acute diarrhoea (defined by WHO as three or more loose stools per day for less than 14 days). Local nurses assessed children and classified their dehydration status using both the DHAKA score and the IMCI algorithm. Serial weights were obtained and dehydration status was established by percentage weight change with rehydration. We did regression analyses to validate the DHAKA score and compared the accuracy and reliability of the DHAKA score and IMCI algorithm with receiver operator characteristic (ROC) curves and the weighted κ statistic. This study was registered with ClinicalTrials.gov, number NCT02007733. Findings Between March 22, 2015, and May 15, 2015, 496 patients were included in our primary analyses. On the basis of our criterion standard, 242 (49%) of 496 children had no dehydration, 184 (37%) of 496 had some dehydration, and 70 (14%) of 496 had severe dehydration. In multivariable regression analyses, each 1-point increase in the DHAKA score predicted an increase of 0·6% in the percentage dehydration of the child and increased the odds of both some and severe dehydration by a factor of 1·4. Both the accuracy and reliability of the DHAKA score were significantly greater than those of the IMCI algorithm. Interpretation The DHAKA score is the first clinical tool for assessing dehydration in children with acute diarrhoea to be externally validated in a low-income country. Further validation studies in a diverse range of settings and paediatric populations are warranted. Funding National Institutes of Health Fogarty International Center.

Sex and Gender Differences in Acute Pediatric Diarrhea: A Secondary Analysis of the DHAKA Study

“…As noted previously, no significant difference was found among children missing data and those included in the final model of the derivation study. In the validation study, those who were lost to follow up did tend to be older, but other significant differences were not found [16]. Given the purpose of this study, we did include 16 children that were excluded in the original derivation study due to significant weight loss.…”

“…These studies were originally designed to derive and validate a clinical dehydration tool for use in low-resource settings. Each was a prospective cohort study; detailed study protocols have been previously published [16,17]. Ethical approval was obtained from the International Centre for Diarrhoeal Disease Research (icddr,b), Bangladesh Ethical Review Committee, and the Rhode Island Hospital (Lifespan) Institutional Review Board.…”

“…The current study aims to understand if boys and girls with acute diarrheal illness differ in severity on presentation, based on a planned secondary analysis of a large data set from Bangladesh. The purpose of the original study was to develop and validate the dehydration: assessing kids accurately (DHAKA) score, a clinical decision tool to assess and guide the treatment of dehydrated children aged 5 years or younger in low resource settings [16,17]. We hypothesize that within this data set, boys are overrepresented due to gendered cultural norms in this region regarding health-seeking behavior that favor medical care for male children, and that boys, therefore, will have less severe dehydration than girls upon presentation.…”

Carotid Flow Time Test Performance for the Detection of Dehydration in Children With Diarrhea

“…We conducted a prospective cohort study of eligible children presenting to the rehydration unit of the International Center for Diarrheal Disease Research in Bangladesh with acute diarrhea. Participants were originally enrolled as part of a validation study of the DHAKA score for dehydration . A subset of these participants were enrolled in the US portion of the study, which was begun only after ethical review was complete.…”

“…The research nurses obtained informed consent and collected baseline demographic and historical data, including age, sex, days of diarrhea, diarrheal episodes in the past 24 hours, and type of diarrhea. The dehydration severity was assessed clinically by the Integrated Management of Childhood Illness algorithm and DHAKA score . The nutritional status was evaluated by measuring the mid–upper arm circumference.…”