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

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FIGURE 1
Flowchart for DHAKA Study Enrollment
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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.
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FIGURE 3
DHAKA Dehydration Decision Tree With Assigned Dehydration Categories

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)	.07^a
Sex				.84^b
Female, No. (%)	336 (44)	6 (38)	26 (41)
Male, No. (%)	435 (56)	10 (62)	37 (59)
Home district				.99^b
Urban (Dhaka), No. (%)	478 (62)	14 (88)	45 (71)
Rural/suburban, No. (%)	293 (38)	2 (12)	18 (29)
Nutritional status (MUAC)				.30^b
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)	.13^a
Loose stools in past 24 hours, median (IQR)	15 (10–20)	15 (11–20)	15 (10–20)	.79^a
Diarrhea type				.69^b
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)

TABLE 2 Association of Clinical Signs With Severe Dehydration in Bivariate Analysis

	Sensitivity	Specificity	PPV	NPV	LR+	LR−	Reliability	Chi-Square	P Value
Eyes							0.60	61.54	<.001
Sunken	0.94	0.13	0.12	0.95	1.08	0.46
Very sunken	0.47	0.87	0.31	0.93	3.55	0.61
General appearance							0.72	64.01	<.001
Restless/irritable	0.84	0.55	0.19	0.96	1.84	0.30
Lethargic/unconscious	0.62	0.77	0.25	0.94	2.69	0.49
Heart rate							0.47	10.28	.006
Fast	0.59	0.57	0.15	0.92	1.38	0.72
Very fast	0.02	0.99	0.33	0.89	4.04	0.98
Mucous membranes							0.42	18.79	<.001
Dry/sticky	0.88	0.34	0.14	0.96	1.35	0.34
Very dry	0.02	0.99	0.25	0.89	2.69	0.99
Radial pulse							0.60	40.77	<.001
Decreased	0.64	0.71	0.21	0.94	2.17	0.52
Weak	0.38	0.84	0.23	0.92	2.37	0.74
Respirations							0.58	35.08	<.001
Deep	0.61	0.69	0.20	0.94	2.00	0.56
Very deep	0.07	0.98	0.33	0.90	4.04	0.95
Skin pinch							0.71	69.18	<.001
Slow	0.85	0.53	0.18	0.97	1.79	0.29
Very slow	0.31	0.93	0.35	0.92	4.37	0.75
Tears							0.63	54.28	<.001
Decreased	0.85	0.52	0.18	0.96	1.75	0.30
Absent	0.29	0.92	0.30	0.91	3.43	0.78

Abbreviations: LR−, negative likelihood ratio; LR+, positive likelihood ratio; NPV, negative predictive value; PPV, positive predictive value.

TABLE 3 12-Point DHAKA Dehydration Scoring System With Assigned Dehydration Categories

Clinical Sign	Finding	Points
General appearance	Normal	0
	Restless/irritable	2
	Lethargic/unconscious	4
Respirations	Normal	0
	Deep	2
Skin pinch	Normal	0
	Slow	2
	Very slow	4
Tears	Normal	0
	Decreased	1
	Absent	2
DHAKA Dehydration Score Categories		Points
No dehydration		0–1
Some dehydration		2–3
Severe dehydration		≥4

TABLE 4 Assigned DHAKA Dehydration Score and DHAKA Dehydration Tree Categories Compared With True Dehydration Status, No. (%)

	DHAKA Dehydration Score Category			DHAKA Dehydration Tree Category
True Dehydration Status	No Dehydration (n = 247)	Some Dehydration (n = 156)	Severe Dehydration (n = 365)	No Dehydration (n = 369)	Some Dehydration (n = 106)	Severe Dehydration (n = 296)
No dehydration	175 (71)	91 (58)	73 (20)	244 (66)	50 (47)	45 (15)
Some dehydration	67 (27)	59 (38)	219 (60)	116 (31)	49 (46)	182 (61)
Severe dehydration	5 (2)	6 (4)	73 (20)	9 (2)	7 (7)	69 (23)

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 dehydration	83% (80%, 87%)	52% (46%, 57%)	69% (65%, 73%)	71% (65%, 77%)	1.7 (1.5, 1.9)	0.33 (0.26, 0.41)
Severe dehydration	87% (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 dehydration	71% (67%, 75%)	72% (67%, 77%)	76% (72%, 81%)	66% (61%, 71%)	2.5 (2.1, 3.0)	0.40 (0.34, 0.47)
Severe dehydration	81% (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.