ABSTRACT
BACKGROUND: Dehydration due to acute gastroenteritis is one of the leading causes of mortality in children worldwide. The World Health Organization (WHO) scale, the Gorelick scale, and the Clinical Dehydration Scale (CDS) were created to estimate percentage dehydration in children with gastroenteritis based on clinical signs. Of these, only the CDS has been prospectively validated against a valid gold standard, though never in low- and middle-income countries. The purpose of this study is to determine whether these clinical scales can accurately assess dehydration status in children when performed by nurses or general physicians in a low-income country. METHODS: We prospectively enrolled a non-consecutive sample of children presenting to three Rwandan hospitals with diarrhea and/or vomiting. A health care provider documented clinical signs on arrival and weighed the patient using a standard scale. Once admitted, the patient received rehydration according to standard hospital protocol and was weighed again at hospital discharge. Receiver operating characteristic (ROC) curves were created for each of the three scales compared to the gold standard, percent weight change with rehydration. Sensitivity, specificity, and likelihood ratios were calculated based on the best cutoff points of the ROC curves. RESULTS: We enrolled 73 children, and 49 children met eligibility criteria. Based on our gold standard, the children had a mean percent dehydration of 5% on arrival. The WHO scale, Gorelick scale, and CDS did not have an area under the ROC curve statistically different from the reference line. The WHO scale had sensitivities of 79% and 50% and specificities of 43% and 61% for severe and moderate dehydration, respectively; the 4- and 10-point Gorelick scale had sensitivities of 64% and 21% and specificities of 69% and 89%, respectively, for severe dehydration, while the same scales had sensitivities of 68% and 82% and specificities of 41% and 35% for moderate dehydration; the CDS had a sensitivity of 68% and specificity of 45% for moderate dehydration. CONCLUSION: In this sample of children, the WHO scale, Gorelick scale, and CDS did not provide an accurate assessment of dehydration status when used by general physicians and nurses in a developing world setting.
ABSTRACT
OBJECTIVES: The objective of this study was to determine the test characteristics for two different ultrasound (US) measures of severe dehydration in children (aorta to inferior vena cava [IVC] ratio and IVC inspiratory collapse) and one clinical measure of severe dehydration (the World Health Organization [WHO] dehydration scale). METHODS: The authors enrolled a prospective cohort of children presenting with diarrhea and/or vomiting to three rural Rwandan hospitals. Children were assessed clinically using the WHO scale and then underwent US of the IVC by a second clinician. All children were weighed on admission and then fluid-resuscitated according to standard hospital protocols. A percent weight change between admission and discharge of greater than 10% was considered the criterion standard for severe dehydration. Receiver operating characteristic (ROC) curves were created for each of the three tests of severe dehydration compared to the criterion standard. RESULTS: Children ranged in age from 1 month to 10 years; 29% of the children had severe dehydration according to the criterion standard. Of the three different measures of dehydration tested, only US assessment of the aorta/IVC ratio had an area under the ROC curve statistically different from the reference line. At its best cut-point, the aorta/IVC ratio had a sensitivity of 93% and specificity of 59%, compared with 93% and 35% for IVC inspiratory collapse and 73% and 43% for the WHO scale. CONCLUSIONS: Ultrasound of the aorta/IVC ratio can be used to identify severe dehydration in children presenting with acute diarrhea and may be helpful in guiding clinical management.
