Prediction of Severe Disease in Children with Diarrhea in a Resource-Limited Setting

Adam C Levine,Vanessa Redditt,Sachita P Shah,Richard M Munyaneza,Peter C Drobac,Valentin Kabemba,Juvenal Musavuli,Hannah C Cockrell,Justin Glavis-Bloom,Mathias Gakwerere,Jean Paul De Charles Umurungi,Bantu Kalimba,Waldemar A Carlo

doi:10.1371/journal.pone.0082386

Abstract

ObjectiveTo investigate the accuracy of three clinical scales for predicting severe disease (severe dehydration or death) in children with diarrhea in a resource-limited setting.MethodsParticipants 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. ResultsThe 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).ConclusionsWhile 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.

Highlights

There were 1.7 billion cases of diarrhea in children in 2011, resulting in 36 million cases of severe disease and 700,000 deaths, or more than 10% of all child deaths worldwide[1]
We investigate the accuracy of three clinical scales, including the World Health Organization (WHO) severe dehydration scale[5], the Centers for Disease Control (CDC) scale[6], and the Clinical Dehydration Scale[9] for predicting severe disease in children with diarrhea admitted to three government hospitals in Rwanda, a low-income country in sub-Saharan Africa
While clinicians may feel that they can intuitively identify which children with diarrhea are severely dehydrated and which ones are not, this study finds that general practice physicians and nurses are likely to both over and under-diagnose severe dehydration based on their overall clinical impression, suggesting an important role for the use of standardized clinical scales when assessing children with diarrhea

Summary

Introduction

There were 1.7 billion cases of diarrhea in children in 2011, resulting in 36 million cases of severe disease and 700,000 deaths, or more than 10% of all child deaths worldwide[1]. For children with mild to moderate dehydration, ORS can be more cost-effective than intravenous fluids, especially in resource-limited settings. There are few tools available to help providers in resource-limited settings predict which children with diarrhea are at risk for severe disease and require hospital admission and intravenous fluids. To overcome the limited accuracy of individual clinical signs, the World Health Organization (WHO) recommends using a combination of four different clinical signs to identify severe dehydration in children with diarrhea, which is considered the standard of care in many low-income countries[5]. The United States Centers for Disease Control (CDC) recommend that providers use a more complex scale of 12 signs and symptoms for evaluating dehydration status in children with diarrhea[6]

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