title: Empirically Derived Dehydration Scoring and Decision Tree Models for Children With Diarrhea: Assessment and Internal Validation in a Prospective Cohort Study in Dhaka, Bangladesh.
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: The Warren Alpert Medical School of Brown University, Providence, RI, USA adam_levine@brown.edu.
authors.forename: Adam C
authors.initials: AC
authors.lastname: Levine
authors.affiliation: The Warren Alpert Medical School of Brown University, Providence, RI, USA.
authors.forename: Justin
authors.initials: J
authors.lastname: Glavis-Bloom
authors.affiliation: The Warren Alpert Medical School of Brown University, Providence, RI, USA.
authors.forename: Payal
authors.initials: P
authors.lastname: Modi
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Sabiha
authors.initials: S
authors.lastname: Nasrin
authors.affiliation: The Warren Alpert Medical School of Brown University, Providence, RI, USA.
authors.forename: Soham
authors.initials: S
authors.lastname: Rege
authors.affiliation: Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA.
authors.forename: Chieh
authors.initials: C
authors.lastname: Chu
authors.affiliation: Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA.
authors.forename: Christopher H
authors.initials: CH
authors.lastname: Schmid
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Nur H
authors.initials: NH
authors.lastname: Alam
mesh_terms: D001459:Bangladesh; D002675:Child, Preschool; D015331:Cohort Studies; D003663:Decision Trees; D003681:Dehydration / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D003967:Diarrhea / Q000150:complications*; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D006801:Humans; D007223:Infant; D008297:Male; D011446:Prospective Studies; D012372:ROC Curve; D015203:Reproducibility of Results; D012720:Severity of Illness Index