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ORIGINAL ARTICLE
Open Access

Empirically Derived Dehydration Scoring and Decision Tree Models for Children With Diarrhea: Assessment and Internal Validation in a Prospective Cohort Study in Dhaka, Bangladesh

Adam C Levine, Justin Glavis-Bloom, Payal Modi, Sabiha Nasrin, Soham Rege, Chieh Chu, Christopher H Schmid and Nur H Alam
Global Health: Science and Practice September 2015, 3(3):405-418; https://doi.org/10.9745/GHSP-D-15-00097
Adam C Levine
aThe Warren Alpert Medical School of Brown University, Providence, RI, USA
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  • For correspondence: adam_levine@brown.edu
Justin Glavis-Bloom
aThe Warren Alpert Medical School of Brown University, Providence, RI, USA
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Payal Modi
aThe Warren Alpert Medical School of Brown University, Providence, RI, USA
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Sabiha Nasrin
bInternational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Soham Rege
aThe Warren Alpert Medical School of Brown University, Providence, RI, USA
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Chieh Chu
cBrown University School of Public Health, Department of Biostatistics, Providence, RI, USA
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Christopher H Schmid
cBrown University School of Public Health, Department of Biostatistics, Providence, RI, USA
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Nur H Alam
bInternational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Figures & Tables

Figures

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  • FIGURE 1
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    FIGURE 1

    Flowchart for DHAKA Study Enrollment

  • FIGURE 2
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    FIGURE 2

    Receiver Operating Characteristic (ROC) Curves of the DHAKA Dehydration Score and DHAKA Dehydration Tree

    Abbreviation: AUC, area under the receiver operating characteristic curve.

  • FIGURE 3
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    FIGURE 3

    DHAKA Dehydration Decision Tree With Assigned Dehydration Categories

Tables

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    TABLE 1 Baseline Characteristics of Enrolled Children <60 Months of Age With Acute Diarrhea, Dhaka, Bangladesh, 2014 (N = 850)
    Included in Final Analysis (n = 771)Excluded, Lost Weight (n = 16)Excluded, No Final Weight (n = 63)P value
    Age in months, median (IQR)15 (9–29)18 (13–29)22 (12–36).07a
    Sex.84b
     Female, No. (%)336 (44)6 (38)26 (41)
     Male, No. (%)435 (56)10 (62)37 (59)
    Home district.99b
     Urban (Dhaka), No. (%)478 (62)14 (88)45 (71)
     Rural/suburban, No. (%)293 (38)2 (12)18 (29)
    Nutritional status (MUAC).30b
     No acute malnutrition, No. (%)614 (80)16 (100)53 (84)
     Moderate acute malnutrition (MAM), No. (%)121 (16)0 (0)7 (11)
     Severe acute malnutrition (SAM), No. (%)35 (4)0 (0)3 (5)
    Days of diarrhea prior to arrival, median (IQR)2 (1–4)2 (1.5–3.5)2 (1–3).13a
    Loose stools in past 24 hours, median (IQR)15 (10–20)15 (11–20)15 (10–20).79a
    Diarrhea type.69b
     Watery, No. (%)448 (58)12 (75)36 (57)
     Rice-water, No. (%)317 (41)4 (25)27 (43)
     Bloody, No. (%)4 (1)0 (0)0 (0)
    • Abbreviation: IQR, interquartile range; MUAC, mid-upper arm circumference.

    • ↵a​ Equality of medians.

    • ↵b​ Chi-square test.

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    TABLE 2 Association of Clinical Signs With Severe Dehydration in Bivariate Analysis
    SensitivitySpecificityPPVNPVLR+LR−ReliabilityChi-SquareP Value
    Eyes0.6061.54<.001
     Sunken0.940.130.120.951.080.46
     Very sunken0.470.870.310.933.550.61
    General appearance0.7264.01<.001
     Restless/irritable0.840.550.190.961.840.30
     Lethargic/unconscious0.620.770.250.942.690.49
    Heart rate0.4710.28.006
     Fast0.590.570.150.921.380.72
     Very fast0.020.990.330.894.040.98
    Mucous membranes0.4218.79<.001
     Dry/sticky0.880.340.140.961.350.34
     Very dry0.020.990.250.892.690.99
    Radial pulse0.6040.77<.001
     Decreased0.640.710.210.942.170.52
     Weak0.380.840.230.922.370.74
    Respirations0.5835.08<.001
     Deep0.610.690.200.942.000.56
     Very deep0.070.980.330.904.040.95
    Skin pinch0.7169.18<.001
     Slow0.850.530.180.971.790.29
     Very slow0.310.930.350.924.370.75
    Tears0.6354.28<.001
     Decreased0.850.520.180.961.750.30
     Absent0.290.920.300.913.430.78
    • Abbreviations: LR−, negative likelihood ratio; LR+, positive likelihood ratio; NPV, negative predictive value; PPV, positive predictive value.

    • View popup
    TABLE 3 12-Point DHAKA Dehydration Scoring System With Assigned Dehydration Categories
    Clinical SignFindingPoints
    General appearanceNormal0
    Restless/irritable2
    Lethargic/unconscious4
    RespirationsNormal0
    Deep2
    Skin pinchNormal0
    Slow2
    Very slow4
    TearsNormal0
    Decreased1
    Absent2
    DHAKA Dehydration Score CategoriesPoints
    No dehydration0–1
    Some dehydration2–3
    Severe dehydration≥4
    • View popup
    TABLE 4 Assigned DHAKA Dehydration Score and DHAKA Dehydration Tree Categories Compared With True Dehydration Status, No. (%)
    DHAKA Dehydration Score CategoryDHAKA Dehydration Tree Category
    True Dehydration StatusNo Dehydration (n = 247)Some Dehydration (n = 156)Severe Dehydration (n = 365)No Dehydration (n = 369)Some Dehydration (n = 106)Severe Dehydration (n = 296)
    No dehydration175 (71)91 (58)73 (20)244 (66)50 (47)45 (15)
    Some dehydration67 (27)59 (38)219 (60)116 (31)49 (46)182 (61)
    Severe dehydration5 (2)6 (4)73 (20)9 (2)7 (7)69 (23)
    • View popup
    TABLE 5 Test Characteristics for DHAKA Dehydration Score and DHAKA Dehydration Tree
    Clinical Diagnostic Model/
    Dehydration Category
    Sensitivity
    (95% CI)
    Specificity
    (95% CI)
    PPV
    (95% CI)
    NPV
    (95% CI)
    LR+
    (95% CI)
    LR−
    (95% CI)
    DHAKA Dehydration Score
    Some dehydration83% (80%, 87%)52% (46%, 57%)69% (65%, 73%)71% (65%, 77%)1.7 (1.5, 1.9)0.33 (0.26, 0.41)
    Severe dehydration87% (80%, 94%)57% (54%, 61%)20% (16%, 24%)97% (96%, 99%)2.0 (1.8, 2.3)0.23 (0.13, 0.40)
    DHAKA Dehydration Tree
    Some dehydration71% (67%, 75%)72% (67%, 77%)76% (72%, 81%)66% (61%, 71%)2.5 (2.1, 3.0)0.40 (0.34, 0.47)
    Severe dehydration81% (73%, 89%)67% (63%, 70%)23% (18%, 28%)97% (95%, 98%)2.5 (2.1, 2.8)0.28 (0.18, 0.44)
    • Abbreviations: CI, confidence interval; LR−, negative likelihood ratio; LR+, positive likelihood ratio; NPV, negative predictive value; PPV, positive predictive value.

Additional Files

  • Figures
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  • GHSP-D-15-00097 Supplementary Material

    Levine et al. doi: 10.9745/GHSP-D-15-00097

    • Supplementary Material - Levine et al. doi: 10.9745/GHSP-D-15-00097
    • Supplementary Material - Levine et al. doi: 10.9745/GHSP-D-15-00097
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Empirically Derived Dehydration Scoring and Decision Tree Models for Children With Diarrhea: Assessment and Internal Validation in a Prospective Cohort Study in Dhaka, Bangladesh
Adam C Levine, Justin Glavis-Bloom, Payal Modi, Sabiha Nasrin, Soham Rege, Chieh Chu, Christopher H Schmid, Nur H Alam
Global Health: Science and Practice Sep 2015, 3 (3) 405-418; DOI: 10.9745/GHSP-D-15-00097

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Empirically Derived Dehydration Scoring and Decision Tree Models for Children With Diarrhea: Assessment and Internal Validation in a Prospective Cohort Study in Dhaka, Bangladesh
Adam C Levine, Justin Glavis-Bloom, Payal Modi, Sabiha Nasrin, Soham Rege, Chieh Chu, Christopher H Schmid, Nur H Alam
Global Health: Science and Practice Sep 2015, 3 (3) 405-418; DOI: 10.9745/GHSP-D-15-00097
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