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.

BackgroundAcute diarrhea remains both common and deadly in children worldwide. Proper treatment depends on accurately assessing dehydration status. Current World Health Organization (WHO) guidelines include an algorithm for classifying children as having no, some, or severe dehydration, which has never been properly validated. The Dehydration: Assessing Kids Accurately (DHAKA) study recently derived a new scoring system for dehydration in children, but it requires external validation.MethodsOur study enrolled a random sample of children with acute diarrhea in Bangladesh. Local nurses prospectively applied both the DHAKA score and the WHO algorithm to children on arrival and obtained serial weights as they were rehydrated. The percent weight change with rehydration was used to classify subjects with severe (>9%) dehydration, some (3%–9%) dehydration, or no (<3%) dehydration. Test characteristics and the area under receiver operator characteristic curves (AUC) were calculated and compared for both diagnostic tools.ResultsA total of 546 children were enrolled, with 488 included in the final analysis. The DHAKA score had an AUC of 0.77 compared to 0.72 for the WHO algorithm for the diagnosis of severe dehydration (p = 0.001) and 0.84 compared to 0.62 for the diagnosis of any dehydration (p < 0.001). The DHAKA score had a sensitivity of 86% and specificity of 54% for diagnosing severe dehydration and 93 and 50% for diagnosing any dehydration.ConclusionThe DHAKA score is now the first dehydration assessment tool both derived and validated in resource‐limited settings, and it outperformed the WHO algorithm. Frontline providers may use this new tool to better manage acute diarrhea in children.DHAKA score.image

The corrected carotid artery flow time was a poor predictor of severe dehydration in this population of children with diarrhea.