The diagnostic accuracy of Clinical Dehydration Scale in identifying dehydration in children with acute gastroenteritis: a systematic review

National Consensus for the Management of Acute Gastroenteritis in Jordanian Children: Consensus Recommendations Endorsed by the Jordanian Paediatric Society

Diarrhoeal diseases are one of the leading worldwide preventable causes of death among children under 5 years of age. Almost half of children do not receive optimal acute gastroenteritis (AGE) treatment in Jordan. With neither regional nor local guidelines available for AGE, consensus recommendations on the management of paediatric AGE in Jordan were developed by a panel of senior paediatricians and paediatric gastroenterologists and are endorsed by the Jordanian Paediatric Society. Recommendations are based on international guidelines and available relevant literature in relation to the AGE landscape and the healthcare system in Jordan. The prevention of diarrhoeal diseases should focus on the improvement of nutrition, hygiene, and sanitation, the introduction of routine vaccination against rotavirus, and the adoption of a standardised approach for AGE management (oral rehydration solution (ORS) use±adjunct therapies, continued feeding, and avoiding routine antibiotic use). Ondansetron, diosmectite, racecadotril, probiotics, and zinc can be considered adjunct to ORS, if needed. Local data gaps should be addressed. The clinical algorithm for the management of paediatric AGE could promote adherence to practice recommendations and by extension improve health outcomes in children.

Sucralfate as an Adjunct to Analgesia to Improve Oral Intake in Children With Infectious Oral Ulcers: A Randomized, Double-Blind, Placebo-Controlled Trial

STUDY HYPOTHESIS

We hypothesized that sucralfate along with oral analgesics (acetaminophen or ibuprofen) administered in the emergency department leads to a clinically significant improvement in oral intake in children with acute infectious oral ulcers.

METHODS

This was a randomized, double-blind, placebo-controlled trial of sucralfate versus placebo conducted between 2017 and 2018 in an urban pediatric emergency department. Children aged 6 months to 5 years with acute, infectious oral ulcers and poor oral intake received either acetaminophen at 15 mg/kg or ibuprofen at 10 mg/kg and were then randomized to receive sucralfate at 20 mg/kg per dose up to 1 g or a placebo solution. The primary outcome was oral fluid intake within 60 minutes of medication administration. The secondary outcomes were repeat ED visits, length of stay in ED, intravenous hydration rate, admission rate, adverse event rate, and emergency physician's determination of the adequacy of oral intake.

RESULTS

One hundred subjects with mild dehydration (clinical dehydration score of 1) and a median age of 1.38 years were enrolled and analyzed (49 in the sucralfate group and 51 in the placebo group). Oral intake 1 hour after drug administration was similar in both the groups: the median intake in the sucralfate group was 9.7 mL/kg and 10.7 mL/kg in the placebo group (difference -1 mL/kg; 95% confidence interval [CI] -2.0 to 4.8). According to the emergency physician's report, the secondary outcomes were significant only for adequate oral intake: 71% in the sucralfate group versus 88% in the placebo group (difference -16.8%; 95% CI -32.2 to -1.4).

CONCLUSION

Sucralfate as an adjunct to oral analgesics was not superior to placebo in improving oral intake in children with acute oral infectious ulcers.

Ultrasound Adds No Benefit to Clinical Exam for Predicting Dehydration in Children With Acute Diarrhea in a Resource-Limited Setting

OBJECTIVES

Diarrhea is one of the most common and deadly conditions affecting children, causing over 525,000 deaths annually, largely in resource-limited settings. Appropriate treatment depends on accurate determination of dehydration status. This study evaluated the accuracy of a new model using clinical and ultrasound measurements for predicting dehydration status in children with acute diarrhea.

METHODS

The Dehydration: Assessing Kids Accurately (DHAKA) study was a prospective cohort study of children under 5 years of age with acute diarrhea presenting to the International Centre for Diarrhoeal Disease Research in Dhaka, Bangladesh. Clinical signs and sonographic measurements of the aorta-to-inferior vena cava ratio were recorded. Percent weight change with rehydration was used to classify dehydration severity. Logistic regression was used to create a combined DHAKA-US model based on clinical and sonographic measurements. Area under the curve and calibration slope were used to assess the model's accuracy and compare it to the original DHAKA score model.

RESULTS

A total of 850 children were enrolled, with 736 included in the final analysis. The combined DHAKA-US model showed equivalent discrimination with the original DHAKA score, with an area under the curve of 0.79 for both models for severe dehydration (95% confidence interval, 0.74-0.84), as well as similar classification (48% versus 50% correctly classified) and calibration (calibration slopes of 0.900 versus 0.904 for presence of any dehydration).

CONCLUSION

Adding sonographic measurements to the DHAKA score had no effect on discrimination, classification, or calibration when compared to the original DHAKA score. Clinical signs alone may be the most important predictors of dehydration status in children with diarrhea in limited resource settings.

Diagnostic accuracy of three clinical dehydration scales: a systematic review

OBJECTIVE

To systematically assess the diagnostic accuracy of the Clinical Dehydration Scale (CDS), the WHO Scale and the Gorelick Scale in identifying dehydration in children with acute gastroenteritis (AGE).

DESIGN

Three databases, two registers of clinical trials and the reference lists from identified articles were searched for diagnostic accuracy studies in children with AGE. The index tests were the CDS, WHO Scale and Gorelick Scale, and reference standard was the percentage loss of body weight. The main analysed outcomes were the sensitivity, specificity, positive likelihood ratio (LR) and negative LR.

RESULTS

Ten studies were included. In high-income countries, the CDS provided a moderate-to-large increase in the post-test probability of predicting moderate to severe (≥6%) dehydration (positive LR 3.9-11.79), but it was of limited value for ruling it out (negative LR 0.55-0.71). In low-income countries, the CDS showed limited value both for ruling in and ruling out moderate-to-severe dehydration. In both settings, the CDS showed poor diagnostic accuracy for ruling in or out no dehydration (<3%) or some dehydration (3%-6%). The WHO Scale showed no or limited value in assessing dehydration in children with diarrhoea. With one exception, the included studies did not confirm the diagnostic accuracy of the Gorelick Scale.

CONCLUSION

Limited evidence suggests that the CDS can help in ruling in moderate-to-severe dehydration (≥6%) in high-income settings only. The WHO and Gorelick Scales are not helpful for assessing dehydration in children with AGE.

The Prevalence and Management of Dehydration amongst Neonatal Admissions to General Paediatric Wards in Kenya-A Clinical Audit

An audit of randomly selected case records of 810 patients admitted to 13 hospitals between December 2015 and November 2016 was done. Prevalence of dehydration was 19.7% (2293 of 11 636) [95% CI: 17.1-22.6%], range across hospitals was 9.4% to 27.0%. Most cases with dehydration were clinically diagnosed (82 of 153; 53.6%), followed by excessive weight loss (54 of 153; 35.3%) and abnormal urea/electrolytes/creatinine (23 of 153; 15.0%). Documentation of fluids prescribed was poor but, where data were available, Ringers lactate (30 of 153; 19.6%) and 10% dextrose (18 of 153; 11.8%) were mostly used. Only 17 of 153 (11.1%) children had bolus fluid prescription, and Ringer's lactate was most commonly used for bolus at a median volume per kilogram body weight of 20 ml/kg (interquartile range, 12-30 ml/kg). Neonatal dehydration is common, but current documentation may underestimate the burden. Heterogeneity in practice likely reflects the absence of guidelines that in turn reflects a lack of research informing practical treatment guidelines.

Diagnostic accuracy of clinical dehydration scales in children

The aim of this study was to evaluate the diagnostic accuracy of the Clinical Dehydration Scale (CDS), the World Health Organization (WHO) scale, and the Gorelick scale for dehydration assessment in children. A prospective, observational study was carried out between October 2014 and December 2016. Eligible participants were children aged 1 month to 5 years with acute diarrhea. After hospital admission, each patient's weight was recorded and the degree of dehydration based on three scales was assessed. The reference standard was the percentage weight change between the discharge and admission weights. The main outcomes were the sensitivity, specificity, positive likelihood ratio (LR), and negative LR. Of 128 children enrolled in the study, complete data were available from 118 patients for analysis. Most of children presented with no or mild dehydration. Only the CDS showed limited value in confirming a diagnosis of dehydration ≥6% (positive LR 3.9, 95% CI 1.1 to 9.1), with no value in ruling it out (negative LR 0.6, 95% CI 0.2 to 0.99).

CONCLUSION

In our cohort, the CDS was of limited diagnostic value in ruling in severe dehydration in children with acute gastroenteritis. The WHO and Gorelick scales were not helpful in the assessment of dehydration. What is Known : • Treatment of acute gastroenteritis (AGE) is based on assessing and correcting the degree of dehydration. • Several scales combining various signs and symptoms have been developed, including the Clinical Dehydration Scale (CDS), and the World Health Organization (WHO) scale, and the Gorelick scale. None of these scales is internationally accepted for best accuracy in diagnosing dehydration in children. What is New: • The CDS was of limited diagnostic value in ruling in severe dehydration in children with AGE. • The WHO and Gorelick scales were not helpful in the assessment of dehydration.

Investigation of the feasibility of non-invasive optical sensors for the quantitative assessment of dehydration

This study explores the feasibility of prospectively assessing infant dehydration using four non-invasive, optical sensors based on the quantitative and objective measurement of various clinical markers of dehydration. The sensors were investigated to objectively and unobtrusively assess the hydration state of an infant based on the quantification of capillary refill time (CRT), skin recoil time (SRT), skin temperature profile (STP) and skin tissue hydration by means of infrared spectrometry (ISP). To evaluate the performance of the sensors a clinical study was conducted on a cohort of 10 infants (aged 6-36 months) with acute gastroenteritis. High sensitivity and specificity were exhibited by the sensors, in particular the STP and SRT sensors, when combined into a fusion regression model (sensitivity: 0.90, specificity: 0.78). The SRT and STP sensors and the fusion model all outperformed the commonly used "gold standard" clinical dehydration scales including the Gorelick scale (sensitivity: 0.56, specificity: 0.56), CDS scale (sensitivity: 1.0, specificity: 0.2) and WHO scale (sensitivity: 0.13, specificity: 0.79). These results suggest that objective and quantitative assessment of infant dehydration may be possible using the sensors investigated. However, further evaluation of the sensors on a larger sample population is needed before deploying them in a clinical setting.

Development of diagnostic sensors for infant dehydration assessment using optical methods

Dehydration resulting from acute diarrhea is one of the leading causes of infant mortality in the developing world. Safe assessment of an infant's hydration level is essential to determine appropriate clinical intervention strategies. However, clinical hydration scales, which are the current gold standard for non-invasive hydration assessment, are often unreliable in lower resource settings. This study presents the development and testing of non-invasive, optical sensors for the objective assessment of dehydration based on the quantitative measurement of skin recoil time, capillary refill time and skin temperature. The results obtained have demonstrated the basic feasibility of using optical sensors for the objective assessment of dehydration. However, several challenges must be overcome before these sensors can be applied in a clinical setting.

Empirically Derived Dehydration Scoring and Decision Tree Models for Children With Diarrhea: Assessment and Internal Validation in a Prospective Cohort Study in Dhaka, Bangladesh

INTRODUCTION

Diarrhea remains one of the most common and most deadly conditions affecting children worldwide. Accurately assessing dehydration status is critical to determining treatment course, yet no clinical diagnostic models for dehydration have been empirically derived and validated for use in resource-limited settings.

METHODS

In the Dehydration: Assessing Kids Accurately (DHAKA) prospective cohort study, a random sample of children under 5 with acute diarrhea was enrolled between February and June 2014 in Bangladesh. Local nurses assessed children for clinical signs of dehydration on arrival, and then serial weights were obtained as subjects were rehydrated. For each child, the percent weight change with rehydration was used to classify subjects with severe dehydration (>9% weight change), some dehydration (3-9%), or no dehydration (<3%). Clinical variables were then entered into logistic regression and recursive partitioning models to develop the DHAKA Dehydration Score and DHAKA Dehydration Tree, respectively. Models were assessed for their accuracy using the area under their receiver operating characteristic curve (AUC) and for their reliability through repeat clinical exams. Bootstrapping was used to internally validate the models.

RESULTS

A total of 850 children were enrolled, with 771 included in the final analysis. Of the 771 children included in the analysis, 11% were classified with severe dehydration, 45% with some dehydration, and 44% with no dehydration. Both the DHAKA Dehydration Score and DHAKA Dehydration Tree had significant AUCs of 0.79 (95% CI = 0.74, 0.84) and 0.76 (95% CI = 0.71, 0.80), respectively, for the diagnosis of severe dehydration. Additionally, the DHAKA Dehydration Score and DHAKA Dehydration Tree had significant positive likelihood ratios of 2.0 (95% CI = 1.8, 2.3) and 2.5 (95% CI = 2.1, 2.8), respectively, and significant negative likelihood ratios of 0.23 (95% CI = 0.13, 0.40) and 0.28 (95% CI = 0.18, 0.44), respectively, for the diagnosis of severe dehydration. Both models demonstrated 90% agreement between independent raters and good reproducibility using bootstrapping.

CONCLUSION

This study is the first to empirically derive and internally validate accurate and reliable clinical diagnostic models for dehydration in a resource-limited setting. After external validation, frontline providers may use these new tools to better manage acute diarrhea in children.