The Effects of Malnutrition and Diarrhea Type on the Accuracy of Clinical Signs of Dehydration in Children under Five: A Prospective Cohort Study in Bangladesh.

Abstract

Acute diarrhea and malnutrition remain significant burdens of disease for children under five and disproportionately affect children living in low- and middle-income countries. Children under five have an estimated 2.9 episodes of diarrhea every year or nearly 1.7 billion episodes of diarrhea in 2010, with the highest burden of disease in Africa and southeast Asia.1 Cholera infection, caused by the O1 or O139 subgroups of the bacterium Vibrio cholerae, is of particular concern because of the severe onset of profuse diarrhea that can cause death from dehydration within hours if untreated.2 Three out of five subregions in Africa report rising numbers of children under five with stunting, a measure of chronic malnutrition, from 46% in 1990 to 58% in 2014.3 Acute malnutrition shows similar geographic distribution, with 68% of children under five suffering from wasting living in Southern Asia and 28% living in Africa.3 Malnutrition is particularly deleterious as it increases the risk of all-cause mortality and can increase the severity and the risk of mortality from common childhood illnesses, including diarrhea. The World Health Organization (WHO) estimates that almost half (45%) of all deaths of children under five are linked to malnutrition.4 Acute and chronic malnutrition as well as micronutrient deficiencies are estimated to contribute to almost 3.1 million child deaths annually.5 In 2013, a pooled analysis of ten prospective studies examining the association of malnutrition and disease-specific mortality found that the largest effects of malnourishment seen in mortality were from diarrheal diseases.6 Conversely, diarrhea can also cause acute malnutrition and, if not addressed properly, frequent bouts can negatively affect child development and lead to chronic malnutrition.7 Prompt and appropriate treatment of dehydration among children under five presenting with acute diarrhea is critical. Several scales have been developed to assess dehydration among children using various clinical signs of dehydration. The Dehydration: Assessing Kids Accurately (DHAKA) Score is an empirically derived scale that was developed and internally validated through the 2014 DHAKA study8 and externally validated in a 2015 validation study.9 The integrated management of childhood illnesses (IMCI) algorithm is a standard algorithm developed by WHO that has been in clinical use for more than a decade.10 The clinical dehydration scale (CDS) was originally developed for use in children under 36 months in 2004 and has since been externally validated for children under five.11,12 Despite the widespread use of these and other clinical scales for assessing the extent of dehydration among children under 5 years in areas in which malnutrition and cholera are endemic, the predictive value of these scales has previously not been independently evaluated in children with malnutrition or those with diarrhea due to cholera. Given the large body of evidence indicating that children with malnutrition are at greater risk of severe morbidity and mortality from diarrheal disease and the substantial global burden of seasonal cholera outbreaks, it is important to ensure that diagnostic tools used to assess the degree of dehydration in children are also accurate in these populations.