title: Prediction of severe disease in children with diarrhea in a resource-limited setting.
abstract: OBJECTIVE
  To investigate the accuracy of three clinical scales for predicting severe disease (severe dehydration or death) in children with diarrhea in a resource-limited setting.
  
  
  METHODS
  Participants included 178 children admitted to three Rwandan hospitals with diarrhea. A local physician or nurse assessed each child on arrival using the World Health Organization (WHO) severe dehydration scale and the Centers for Disease Control (CDC) scale. Children were weighed on arrival and daily until they achieved a stable weight, with a 10% increase between admission weight and stable weight considered severe dehydration. The Clinical Dehydration Scale was then constructed post-hoc using the data collected for the other two scales. Receiver Operator Characteristic (ROC) curves were constructed for each scale compared to the composite outcome of severe dehydration or death.
  
  
  RESULTS
  The WHO severe dehydration scale, CDC scale, and Clinical Dehydration Scale had areas under the ROC curves (AUCs) of 0.72 (95% CI 0.60, 0.85), 0.73 (95% CI 0.62, 0.84), and 0.80 (95% CI 0.71, 0.89), respectively, in the full cohort. Only the Clinical Dehydration Scale was a significant predictor of severe disease when used in infants, with an AUC of 0.77 (95% CI 0.61, 0.93), and when used by nurses, with an AUC of 0.78 (95% CI 0.63, 0.93).
  
  
  CONCLUSIONS
  While all three scales were moderate predictors of severe disease in children with diarrhea, scale accuracy varied based on provider training and age of the child. Future research should focus on developing or validating clinical tools that can be used accurately by nurses and other less-skilled providers to assess all children with diarrhea in resource-limited settings.
authors.affiliation: Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America.
authors.forename: Adam C
authors.initials: AC
authors.lastname: Levine
authors.affiliation: Department of Community Health, Rwanda Ministry of Health, Kigali, Kigali Province, Rwanda.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Munyaneza
authors.affiliation: Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America.
authors.forename: Justin
authors.initials: J
authors.lastname: Glavis-Bloom
authors.affiliation: Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Redditt
authors.affiliation: Watson Institute for International Studies, Brown University, Providence, Rhode Island, United States of America.
authors.forename: Hannah C
authors.initials: HC
authors.lastname: Cockrell
authors.affiliation: Department of Medicine, Kirehe Hospital, Kirehe, Eastern Province, Rwanda.
authors.forename: Bantu
authors.initials: B
authors.lastname: Kalimba
authors.affiliation: Department of Medicine, Kirehe Hospital, Kirehe, Eastern Province, Rwanda.
authors.forename: Valentin
authors.initials: V
authors.lastname: Kabemba
authors.affiliation: Department of Medicine, Butaro Hospital, Butaro, Northern Province, Rwanda.
authors.forename: Juvenal
authors.initials: J
authors.lastname: Musavuli
authors.affiliation: Department of Medicine, Butaro Hospital, Butaro, Northern Province, Rwanda.
authors.forename: Mathias
authors.initials: M
authors.lastname: Gakwerere
authors.affiliation: Department of Public Health, University of New South Wales, Randwick, New South Wales, Australia.
authors.forename: Jean Paul de Charles
authors.initials: JP
authors.lastname: Umurungi
authors.affiliation: Division of Emergency Medicine, University of Washington Medical Center, Seattle, Washington, United States of America.
authors.forename: Sachita P
authors.initials: SP
authors.lastname: Shah
authors.affiliation: Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America ; Research Department, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Eastern Province, Rwanda.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Drobac
mesh_terms: D001835:Body Weight; D002648:Child; D002675:Child, Preschool; D003967:Diarrhea / Q000453:epidemiology*; D005260:Female; D006295:Health Resources; D006801:Humans; D007223:Infant; D008297:Male; D012372:ROC Curve; D012432:Rwanda / Q000453:epidemiology