Online Program

Assessing the accuracy of three clinical dehydration scales in children with diarrhea in a resource-limited setting

Tuesday, November 5, 2013

Adam Levine, MD, MPH, Warren Alpert Medical School, Brown University, Providence, RI
Richard B. Mark Munyaneza, MD, Ministry of Health of Rwanda, Kigali, Rwanda
Hannah Cockrell, BA, Development Studies Program, Watson Institute for International Studies, Brown University, Providence, RI
Justin Glavis-Bloom, BA, Warren Alpert Medical School of Brown University, Providence, RI
Background: Diarrhea accounts for nearly one-fifth of child deaths worldwide. Since assessing dehydration status is critical to providing appropriate treatment and preventing death in children with diarrhea, we evaluate the accuracy of three popular clinical dehydration scales.

Methods: We prospectively enrolled children admitted with diarrhea to three rural Rwandan hospitals. A nurse or physician assessed each child using the World Health Organization (WHO), Gorelick, and Clinical Dehydration Scale (CDS). Children were rehydrated according to hospital protocols and weighed daily, with greater than 10% change between admission and stable weight considered as severe dehydration. Receiver operating characteristic (ROC) curves were created for each of the three scales compared to the composite outcome of severe dehydration or death.

Findings: 170 children under five were enrolled. The WHO, CDS, and Gorelick scales were all moderate predictors of our composite outcome, with area under the ROC curves (AUC) of 0.680 (p=.028), 0.733 (p=.004), and 0.691 (p=.019), respectively. When limited to patients evaluated by a nurse, only the CDS had a statistically significant AUC of 0.753 (p=.028). In patients evaluated by a physician, the WHO, CDS, and Gorelick scales had AUCs of 0.765 (p=.023), 0.761 (p=.025), and 0.794 (p=.011), respectively.

Interpretation: While all three scales were moderate predictors of dehydration or death, their accuracy differed by provider type. In particular, the WHO scale did not perform well when used by nurses, the front-line providers of pediatric care in most resource-limited settings. Further research is necessary to determine the best clinical dehydration scale in these settings.

Learning Areas:

Clinical medicine applied in public health
Conduct evaluation related to programs, research, and other areas of practice
Provision of health care to the public
Public health or related organizational policy, standards, or other guidelines
Public health or related research

Learning Objectives:
Describe the importance of accurately assessing dehydration status in children with diarrhea in resource-limited settings Evaluate the performance of three popular clinical dehydration scales when used by physicians and nurses working in resource-limited settings

Keyword(s): Diarrhea, Developing Countries

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: As a co-author of this study, I became well-versed in the previous literature regarding pediatric diarrhea assessment, the methods we employed in our study, and our findings and their relevance for practioners and policymakers. Among my scientific interests has been emergency medicine in resource limited settings and infectious causes of mortality.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.