External Validation of the DHAKA Score for Diagnosing Severe Dehydration in Children with Acute Diarrhea in Resource‐limited Settings

Abstract

Background: Acute diarrhea remains both common and deadly in children worldwide. Proper treatment depends on accurately assessing dehydration status. Current World Health Organization (WHO) guidelines include an algorithm for classifying children as having no, some, or severe dehydration, which has never been prospectively validated. The Dehydration: Assessing Kids Accurately (DHAKA) study recently derived a new scoring system for dehydration in children, but it also requires external validation. Objectives: Validate the DHAKA Score in a new population of children with acute diarrhea and compare its accuracy to the WHO algorithm. Methods: This study enrolled a random sample of children with acute diarrhea at an urban hospital in Bangladesh. Local nurses prospectively applied both the DHAKA score and WHO algorithm to children on arrival and obtained serial weights as they were rehydrated. The percent weight change with rehydration was used to classify subjects with severe (>9%) dehydration, some (3-9%) dehydration, or no (<3%) dehydration, based on standards in the pediatric literature. Test characteristics and the area under receiver-operator characteristic curves (AUC) were calculated and compared for both diagnostic tools. Results: 546 children were enrolled, with 488 included in the final analysis. 48% of children had no dehydration, 38% had some dehydration, and 14% had severe dehydration. The DHAKA score had an AUC of 0.77 compared to 0.72 for the WHO algorithm for the diagnosis of severe dehydration (p=0.001), and an AUC of 0.84 compared to 0.62 for the diagnosis of any dehydration (p<0.001). The DHAKA score had a sensitivity of 86% and specificity of 54% for diagnosing severe dehydration and 93% and 50% for diagnosing any dehydration. Conclusion: The DHAKA score is the first dehydration assessment tool both derived and validated in a resource-limited setting, and outperformed the WHO algorithm. Frontline providers may now use this new tool to better manage acute diarrhea in children worldwide.