Stool frequency recording in severe acute malnutrition (‘StoolSAM’); an agreement study comparing maternal recall versus direct observation using diapers

Abstract

BackgroundApproximately 50% of the deaths of children under the age of 5 can be attributed to undernutrition, which also encompasses severe acute malnutrition (SAM). Diarrhoea is strongly associated with these deaths and is commonly diagnosed solely based on stool frequency and consistency obtained through maternal recall. This trial aims to determine whether this approach is equivalent to a ‘directly observed method’ in which a health care worker directly observed stool frequency using diapers in hospitalised children with complicated SAM.MethodsThis study was conducted at ‘Moyo’ Nutritional Rehabilitation Unit, Queen Elizabeth Central Hospital, Malawi. Participants were children aged 5–59 months admitted with SAM. We compared 2 days of stool frequency data obtained with next-day maternal-recall versus a ‘gold standard’ in which a health care worker observed stool frequency every 2 h using diapers. After study completion, guardians were asked their preferred method and their level of education.ResultsWe found poor agreement between maternal recall and the ‘gold standard’ of directly observed diapers. The sensitivity to detect diarrhoea based on maternal recall was poor, with only 75 and 56% of diarrhoea cases identified on days 1 and 2, respectively. However, the specificity was higher with more than 80% of children correctly classified as not having diarrhoea. On day 1, the mean stool frequency difference between the two methods was −0.17 (SD; 1.68) with limits of agreement (of stool frequency) of −3.55 and 3.20 and, similarly on day 2, the mean difference was −0.2 (SD; 1.59) with limits of agreement of −3.38 and 2.98. These limits extend beyond the pre-specified ‘acceptable’ limits of agreement (±1.5 stool per day) and indicate that the 2 methods are non-equivalent. The higher the stool frequency, the more discrepant the two methods were. Most primary care givers strongly preferred using diapers.ConclusionsThis study shows lack of agreement between the assessment of stool frequency in SAM patients using maternal recall and direct observation of diapers. When designing studies, one should consider using diapers to determining diarrhoea incidence/prevalence in SAM patients especially when accuracy is essential.Trial registration number ISRCTN11571116 (registered 29/11/2013).Electronic supplementary materialThe online version of this article (doi:10.1186/s12887-017-0874-0) contains supplementary material, which is available to authorized users.

A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial

“…Although there is some subjectivity in determining a child’s medical condition that is “improving,” we chose stabilization as a main outcome rather than episodes of diarrhea because 1) it is the purpose of F75; 2) once a child switches to F100 or RUTFs, earlier transition could conceivably result in an increase in diarrhea unrelated to mF75 or F75; 3) diarrhea is very difficult to quantify objectively since maternal recall is not accurate in identifying episodes or severity [25]; 4) diapers may not distinguish every stool episode, and their weight is affected by urine; and 5) refeeding syndrome may be critical to early outcomes.…”

Effectiveness of SMS messaging for diarrhoea measurement: a factorial cross-over randomised controlled trial

“…The study was unable to ascertain the impact of perception bias and if participants truly understand what de nes a case of diarrhoea. For example, in a previous study, Voskuijl and colleagues (2017) found that parents of infants with severe acute malnutrition in a Malawian hospital were only able to identify 75% of loose or watery stools as such (loose or watery stools being identi ed by observation by a health care provider) [17].…”

Effectiveness of SMS messaging for diarrhoea measurement: a factorial cross-over randomised controlled trial

“…2) The study was unable to ascertain the impact of perception bias and if participants truly understand what defines a case of diarrhoea. For example, in a previous study, Voskuijl and colleagues (2017) found that parents of infants with severe acute malnutrition in a Malawian hospital were only able to identify 75% of loose or watery stools as such (loose or watery stools being identified by observation by a health care provider) [16].…”