[Multicenter validation of the clinical dehydration scale for children]

A comparison of the NIRUDAK models and WHO algorithm for dehydration assessment in older children and adults with acute diarrhoea: a prospective, observational study

BACKGROUND

Despite the importance of accurate and rapid assessment of hydration status in patients with acute diarrhoea, no validated tools exist to help clinicians assess dehydration severity in older children and adults. The aim of this study is to validate a clinical decision support tool (CDST) and a simplified score for dehydration severity in older children and adults with acute diarrhoea (both developed during the NIRUDAK study) and compare their accuracy and reliability with current WHO guidelines.

METHODS

A random sample of patients aged 5 years or older presenting with diarrhoea to the icddr,b Dhaka Hospital in Bangladesh between Jan 30 and Dec 13, 2022 were included in this prospective cohort study. Patients with fewer than three loose stools per day, more than 7 days of symptoms, previous enrolment in the study, or a diagnosis other than acute gastroenteritis were excluded. Patients were weighed on arrival and assessed separately by two nurses using both our novel clinical tools and WHO guidelines. Patients were weighed every 4 h to determine their percent weight change with rehydration, our criterion standard for dehydration. Accuracy for the diagnosis of dehydration category (none, some, or severe) was assessed using the ordinal c-index (ORC). Reliability was assessed by comparing the prediction of severe dehydration from each nurse's independent assessment using the intraclass correlation coefficient (ICC).

FINDINGS

1580 patients were included in our primary analysis, of whom 921 (58·3%) were female and 659 (41·7%) male. The ORC was 0·74 (95% CI 0·71-0·77) for the CDST, 0·75 (0·71-0·78) for the simplified score, and 0·64 (0·61-0·67) for the WHO guidelines. The ICC was 0·98 (95% CI 0·97-0·98) for the CDST, 0·94 (0·93-0·95) for the simplified score, and 0·56 (0·52-0·60) for the WHO guidelines.

INTERPRETATION

Use of our CDST or simplified score by clinicians could reduce undertreatment and overtreatment of older children and adults with acute diarrhoea, potentially reducing morbidity and mortality for this common disease.

FUNDING

US National Institutes of Health.

TRANSLATION

For the Bangla translation of the abstract see Supplementary Materials section.

A systematic review of tools for predicting complications in patients with acute infectious diarrhea

OBJECTIVE

To identify tools that predict the risk of complications in patients presenting to outpatient clinics or emergency departments (ED) with acute infectious diarrhea.

METHODS

Medline, Embase, Cochrane Library, Web of Science and CINAHL were searched from inception to July 2021. Articles reporting on the derivation or validation of a score to stratify the risk of intravenous rehydration or hospitalization among patients with acute infectious diarrhea in the ED or outpatient clinic were retained for analysis.

RESULTS

Five articles reporting on two different tools were identified. Developed to assess the risk of hospitalization of children, the EsVida scale has not been externally validated. Developed originally to assess the level of dehydration in children, the Clinical Dehydration Scale (CDS) was evaluated as a risk stratification tool. For predicting intravenous rehydration, a CDS score ≥ 1 showed a sensitivity between 0.73 and 0.88 and specificity between 0.38 and 0.69, whereas a CDS score ≥ 5 showed a sensitivity between 0.06 and 0.32 and specificity between 0.94 and 0.99. For predicting hospitalization, a CDS score ≥ 1 showed a sensitivity between 0.74 and 1.00 and specificity between 0.34 and 0.38, whereas a CDS score ≥ 5 showed a sensitivity between 0.26 and 0.62 and specificity between 0.66 and 0.96. High heterogeneity among studies and unclear risk of bias precluded meta-analysis.

CONCLUSION

As a risk-stratification tool, the CDS has been validated only for children. Further research is needed to develop and validate a tool suitable for adults in the ED.

Impact of body characteristics on ultrasound-measured inferior vena cava parameters in Chinese children

Ultrasound-measured inferior vena cava (IVC) and abdominal aorta (Ao)-associated parameters have been used to predict volume status for decades, yet research focusing on the impact of individual physical characteristics, including gender, height/weight, body surface area (BSA), and age, assessed simultaneously on those parameters in Chinese children is lacking. The aim of the present study was to explore the impact of individual characteristics on maximum IVC diameter (IVCmax), Ao, and IVCmax/Ao in healthy Chinese children. From September to December 2015, 200 healthy children from 1 to 13 years of age were enrolled. IVCmax and Ao diameters were measured by 2D ultrasound. We found that age (years), height (cm), weight (kg), waist circumference (cm), and BSA (m²) were positively correlated with IVCmax and Ao. Multivariate linear regression showed that age was the only independent variable for IVCmax (mm) in female children, height was the only independent variable for IVCmax in male children, and age was the only independent variable for Ao in both females and males. IVCmax/Ao was not significantly influenced by the subjects’ characteristics. In conclusion, IVCmax and Ao were more susceptible to subjects’ characteristics than IVCmax/Ao. IVCmax/Ao could be a reliable and practical parameter in Chinese children as it was independent of age, height, and weight.

Non-invasive Assessment of Significant Dehydration in Infants Using the Inferior Vena Cava to Aortic Ratio: Is it Useful?

OBJECTIVES

The aim of the study was to assess the accuracy of the inferior vena cava to aorta (IVC/Ao) diameter ratio for predicting significant dehydration in infants relative to their percentage weight change and the clinical diagnosis by a physician.

METHODS

A prospective observational study was performed on 200 infants presented with acute diarrhea and clinical evidence of significant dehydration whose treatment required intravenous (IV) fluids as determined by the attending physician at the pediatric emergency department of Tanta University Hospital. Weight was recorded at admission before IV fluid treatment and at hospital discharge. The percentage of dehydration was determined using the following formula: (discharge weight - admission weight)/discharge weight × 100%. Patients with a percentage weight change of <5% were considered to be nonsignificantly dehydrated, whereas patients with a percentage weight change >5% were considered significantly dehydrated. The IVC/Ao diameter ratio was measured for all patients before IV fluid rehydration and again at discharge.

RESULTS

Only 134 out of 200 dehydrated infants were found to be significantly dehydrated using the gold standard, percentage weight change. Receiver operating characteristics (ROC) curve analysis of the prehydration IVC/Ao ratio showed a sensitivity of 82%, a specificity of 91%, and an accuracy of 87% for predicting significant dehydration in infants at a cut-off point of less than 0.75. In contrast, physician clinical diagnosis showed a sensitivity of 70%, a specificity of 63%, and an accuracy of 73%.

CONCLUSIONS

The IVC/Ao diameter ratio can be used as a reliable predictor for diagnosing significant dehydration in infants.

Diagnostic accuracy of three clinical dehydration scales: a systematic review

OBJECTIVE

To systematically assess the diagnostic accuracy of the Clinical Dehydration Scale (CDS), the WHO Scale and the Gorelick Scale in identifying dehydration in children with acute gastroenteritis (AGE).

DESIGN

Three databases, two registers of clinical trials and the reference lists from identified articles were searched for diagnostic accuracy studies in children with AGE. The index tests were the CDS, WHO Scale and Gorelick Scale, and reference standard was the percentage loss of body weight. The main analysed outcomes were the sensitivity, specificity, positive likelihood ratio (LR) and negative LR.

RESULTS

Ten studies were included. In high-income countries, the CDS provided a moderate-to-large increase in the post-test probability of predicting moderate to severe (≥6%) dehydration (positive LR 3.9-11.79), but it was of limited value for ruling it out (negative LR 0.55-0.71). In low-income countries, the CDS showed limited value both for ruling in and ruling out moderate-to-severe dehydration. In both settings, the CDS showed poor diagnostic accuracy for ruling in or out no dehydration (<3%) or some dehydration (3%-6%). The WHO Scale showed no or limited value in assessing dehydration in children with diarrhoea. With one exception, the included studies did not confirm the diagnostic accuracy of the Gorelick Scale.

CONCLUSION

Limited evidence suggests that the CDS can help in ruling in moderate-to-severe dehydration (≥6%) in high-income settings only. The WHO and Gorelick Scales are not helpful for assessing dehydration in children with AGE.

Corrigendum

Falszewska A, Dziechciarz P, Szajewska H. The diagnostic accuracy of Clinical Dehydration Scale in identifying dehydration in children with acute gastroenteritis: a systematic review. Clin Pediatr (Phila). 2014;53:1181-8. (Original DOI: 10.1177/0009922814538493 ).

Association between oropharyngeal carriage of Kingella kingae and osteoarticular infection in young children: a case-control study

BACKGROUND

Kingella kingae has been increasingly identified in patients with osteoarticular infections. Our main objective was to evaluate the association between carriage of K. kingae in the oropharynx of preschool children and osteoarticular infections.

METHODS

We conducted this prospective case-control study in 2 tertiary care pediatric hospitals (Canada and Switzerland) between 2014 and 2016. Potential cases were children aged 6 to 48 months with a presumptive diagnosis of osteoarticular infection according to the treating emergency physician. Confirmed cases were those with diagnosis of osteomyelitis or septic arthritis proven by positive findings on technetium-labelled bone scan or magnetic resonance imaging or identification of a microorganism in joint aspirate or blood. For each case, we recruited 4 age-matched controls from among children presenting to the same emergency department for trauma. The independent variable was presence of oropharyngeal K. kingae DNA identified by a specific polymerase chain reaction assay. We determined the association between oropharyngeal carriage of K. kingae and definitive osteoarticular infection.

RESULTS

The parents of 77 children admitted for suspected osteoarticular infection and 286 controls were invited to participate and provided informed consent. We identified K. kingae in the oropharynx of 46 (71%) of 65 confirmed cases and 17 (6%) of 286 controls; these results yielded an odds ratio of 38.3 (95% confidence interval 18.5-79.1).

INTERPRETATION

Detection of oropharyngeal K. kingae was strongly associated with osteoarticular infection among children presenting with symptoms suggestive of such infection.

Diagnostic accuracy of clinical dehydration scales in children

The aim of this study was to evaluate the diagnostic accuracy of the Clinical Dehydration Scale (CDS), the World Health Organization (WHO) scale, and the Gorelick scale for dehydration assessment in children. A prospective, observational study was carried out between October 2014 and December 2016. Eligible participants were children aged 1 month to 5 years with acute diarrhea. After hospital admission, each patient's weight was recorded and the degree of dehydration based on three scales was assessed. The reference standard was the percentage weight change between the discharge and admission weights. The main outcomes were the sensitivity, specificity, positive likelihood ratio (LR), and negative LR. Of 128 children enrolled in the study, complete data were available from 118 patients for analysis. Most of children presented with no or mild dehydration. Only the CDS showed limited value in confirming a diagnosis of dehydration ≥6% (positive LR 3.9, 95% CI 1.1 to 9.1), with no value in ruling it out (negative LR 0.6, 95% CI 0.2 to 0.99).

CONCLUSION

In our cohort, the CDS was of limited diagnostic value in ruling in severe dehydration in children with acute gastroenteritis. The WHO and Gorelick scales were not helpful in the assessment of dehydration. What is Known : • Treatment of acute gastroenteritis (AGE) is based on assessing and correcting the degree of dehydration. • Several scales combining various signs and symptoms have been developed, including the Clinical Dehydration Scale (CDS), and the World Health Organization (WHO) scale, and the Gorelick scale. None of these scales is internationally accepted for best accuracy in diagnosing dehydration in children. What is New: • The CDS was of limited diagnostic value in ruling in severe dehydration in children with AGE. • The WHO and Gorelick scales were not helpful in the assessment of dehydration.

Comparison of Recommendations in Clinical Practice Guidelines for Acute Gastroenteritis in Children

OBJECTIVE

Acute gastroenteritis (AGE) is a major cause of child mortality and morbidity. This study aimed at systematically reviewing clinical practice guidelines (CPGs) on AGE to compare recommendations and provide the basis for developing single universal guidelines.

METHODS

CPGs were identified by searching MEDLINE, Cochrane-Library, National Guideline Clearinghouse and Web sites of relevant societies/organizations producing and/or endorsing CPGs.

RESULTS

The definition of AGE varies among the 15 CPGs identified. The parameters most frequently recommended to assess dehydration are skin turgor and sunken eyes (11/15, 73.3%), general appearance (11/15, 66.6%), capillary refill time, and mucous membranes appearance (9/15, 60%). Oral rehydration solution is universally recognized as first-line treatment. The majority of CPGs recommend hypo-osmolar (Na 45-60 mmol/L, 11/15, 66.6 %) or low-osmolality (Na 75 mmol/L, 9/15, 60%) solutions. In children who fail oral rehydration, most CPGs suggest intravenous rehydration (66.6%). However, nasogastric tube insertion for fluid administration is preferred according by 5/15 CPGs (33.3%). Changes in diet and withdrawal of food are discouraged by all CPGs, and early refeeding is strongly recommended in 13 of 15 (86.7%). Zinc is recommended as an adjunct to ORS by 10 of 15 (66.6%) CPGs, most of them from low-income countries. Probiotics are considered by 9 of 15 (60%) CPGs, 5 from high-income countries. Antiemetics are not recommended in 9 of 15 (60%) CPGs. Routine use of antibiotics is discouraged.

CONCLUSIONS

Key recommendations for the management of AGE in children are similar in CPGs. Together with accurate review of evidence-base this may represent a starting point for developing universal recommendations for the management of children with AGE worldwide.

An international consensus report on a new algorithm for the management of infant diarrhoea

AIM

Implementing international guidelines guarantees high standards of clinical care. A group of experts developed an algorithm to drive the management of common gastrointestinal symptoms in infancy by paediatricians and general practitioners.

METHODS

The algorithm started from the evidence-based recommendations of the European Society of Gastroenterology, Hepatology and Nutrition and the European Society of Pediatric Infectious Diseases and an updated review of the literature. We used the structured quantitative method of nominal group technique to reach a consensus.

RESULTS

A practical algorithm for the management of infants with acute diarrhoea was designed based on the consensus reached for each statement. The management of an infant with acute diarrhoea should include a sequence of actions: (i) a semiquantitative estimate of infant dehydration through validated clinical scores, (ii) rehydration therapy and early refeeding with breast milk or regular formula and (iii) effective agents to reduce the severity and duration of the diarrhoea. Finally, in children with prolonged diarrhoea, the search for aetiology should include persistent infections or reinfections, cows' milk protein allergy and coeliac diseases. Lactose should always be withdrawn.

CONCLUSION

This algorithm provides an evidence-based sequence of interventions to optimise the management of infants with acute diarrhoea.

Evaluation of an oral electrolyte solution for treatment of mild to moderate dehydration in dogs with hemorrhagic diarrhea

OBJECTIVE

To determine the safety and efficacy of an electrolyte solution for oral administration (OES) for the correction of mild to moderate dehydration associated with hemorrhagic diarrhea in dogs.

DESIGN

Nonrandomized, noncontrolled clinical trial.

ANIMALS

20 dogs that had hemorrhagic diarrhea with < 3 episodes of vomiting.

PROCEDURES

All dogs underwent testing for parvovirus infection, were given maropitant citrate to control emesis, and were offered an OES. Intravenous crystalloid fluid administration was performed when dogs refused the OES or had vomiting, a 5% increase in PCV, 5% decrease in body weight, serum creatinine or BUN concentration higher than at admission, or clinically important alterations in blood electrolyte or serum glucose concentrations.

RESULTS

13 (65%) dogs voluntarily consumed the OES; 7 (35%) dogs refused the OES and received a balanced electrolyte solution IV instead. All 13 dogs in the OES group consumed the solution ≤ 5 hours after hospital admission. Eight and 16 hours after admission, PCV and serum total protein and BUN concentrations were significantly lower than at hospital admission in the OES group, whereas no significant changes were identified in venous blood pH, base excess, and concentrations of sodium, potassium, chloride, ionized calcium, ionized magnesium, and lactate. The cost of treatment was significantly less for the OES group than for the IV treated group.

CONCLUSIONS AND CLINICAL RELEVANCE

Rehydration therapy with an OES was effective and safe in dogs with mild to moderate dehydration associated with hemorrhagic diarrhea. Potential benefits of this treatment approach for gastroenteritis in dogs, compared with traditional IV fluid administration, include lower owner-related veterinary costs and decreased staff time associated with treatment.

Disidratazione acuta da gastroenterite nei lattanti

Il bambino sotto 1 anno e, soprattutto, di meno di 6 mesi è ad alto rischio di disidratazione, la cui causa principale è una gastroenterite acuta, soprattutto di origine virale. La gestione di una disidratazione da gastroenterite ha due componenti: la sua correzione e il rapido ripristino della normale perfusione tissutale e il mantenimento dei fabbisogni di acqua e di nutrienti, per limitare al massimo il deficit energetico. La valutazione della gravità della disidratazione è l’elemento chiave che guiderà la terapia. La perdita di peso, espressa in percentuale di peso corporeo prima dell’episodio di disidratazione, è il metodo di riferimento, ma è spesso difficile o impossibile da ottenere. Inoltre, i segni clinici, come l’alterazione dell’aspetto generale, l’allungamento del tempo di riempimento capillare, il riconoscimento di una plica cutanea persistente, gli occhi infossati, una secchezza delle mucose e la mancanza di lacrime, sono i principali elementi che permettono di valutare la gravità della disidratazione. Il trattamento si basa sulla rapida correzione del deficit del settore extracellulare. Un’espansione volemica di 20 ml/kg di una soluzione isotonica somministrata per via endovenosa o intraossea può essere necessaria nella fase iniziale nei casi più gravi (disidratazione > 10%). In tutti gli altri casi, la reidratazione per via orale per correggere il deficit di acqua in 4-6 ore è la tecnica di scelta, che si è dimostrata efficace, sicura e veloce. Essa utilizza delle soluzioni di reidratazione adattate che soddisfano criteri specifici. Il loro utilizzo precoce è la prevenzione più efficace delle forme gravi. L’allattamento al seno non deve essere interrotto e l’alimentazione artificiale deve essere ripresa da 4 a 6 ore dopo l’inizio della reidratazione. La vaccinazione contro i rotavirus prima dei 6 mesi è fortemente raccomandata.

Comparing the Accuracy of the Three Dehydration Scales in Children with Acute Diarrhea in a Developing Country of Kosovo

BACKGROUND

Although diarrhea is a preventable disease, it remains the second leading cause of death (after pneumonia) among children aged under five years worldwide. The World Health Organization (WHO) scale, the Gorelick scale, and the Clinical Dehydration Scale (CDS) were created to estimate dehydration status using clinical signs. The purpose of this study is to determine whether these clinical scales can accurately assess dehydration status of children in a developing country of Kosovo.

METHODOLOGY

Children aged 1 month to 5 years with a history of acute diarrhea were enrolled in the study. After recording the data about the patients historical features the treating physician recorded the physical examination findings consistent with each clinical score. Receiver operating characteristic (ROC) curves were constructed to evaluate the performance of the three scales, compared to the gold standard, percent weight change with rehydration. Sensitivity, specificity and likelihood ratios were calculated using the best cut-off points of the ROC curves.

RESULTS

We enrolled 230 children, and 200 children met eligibility criteria. The WHO scale for predicting significant dehydration (≥5 percent weight change) had an area under the curve (AUC) of 0.71 (95% : CI= 0.65-0.77). The Gorelick scales 4- and 10-point for predicting significant dehydration, had an area under the curve of 0.71 (95% : CI=0.63- 0.78) and 0.74 (95% : CI= 0.68-0.81) respectively. Only the CDS for predicting the significant dehydration above ≥6% percent weight change, did not have an area under the curve statistically different from the reference line with an AUC of 0.54 (95% CI = 0.45- 0.63).

CONCLUSION

The WHO dehydration scale and Gorelick scales were fair predictors of dehydration in children with diarrhea. Only the Clinical Dehydration Scale was found not to be a helpful predictor of dehydration in our study cohort.

Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis

OBJECTIVE

To determine the most accurate, noninvasive method of assessing dehydration.

STUDY DESIGN

The following data sources were searched: electronic databases, gray literature, scientific meetings, reference lists, and authors of unpublished studies. Eligible studies were comparative outpatient evaluations that used an accepted reference standard and were conducted in developed countries in children aged <18 years with gastroenteritis. Data extraction was completed independently by multiple reviewers before a consensus was made.

RESULTS

Nine studies that included 1039 participants were identified. The 4-item Clinical Dehydration Scale (CDS), the "Gorelick" score, and unstructured physician assessment were evaluated in 3, 2, and 5 studies, respectively. Bedside ultrasound, capillary digital videography, and urinary measurements were each evaluated in one study. The CDS had a positive likelihood ratio (LR) range of 1.87-11.79 and a negative LR range of 0.30-0.71 to predict 6% dehydration. When combined with the 4-item Gorelick Score, the positive LR was 1.93 (95% CI 1.07-3.49) and negative LR was of 0.40 (95% CI 0.24-0.68). Unstructured dehydration assessment had a pooled positive LR of 2.13 (95% CI 1.33-3.44) and negative LR of 0.48 (95% CI 0.28-0.82) to detect ≥ 5% dehydration.

CONCLUSIONS

Overall, the clinical scales evaluated provide some improved diagnostic accuracy. However, test characteristics indicate that their ability to identify children both with and without dehydration is suboptimal. Current evidence does not support the routine use of ultrasound or urinalysis to determine dehydration severity.

The diagnostic accuracy of Clinical Dehydration Scale in identifying dehydration in children with acute gastroenteritis: a systematic review

AIM

To systematically update diagnostic accuracy of the Clinical Dehydration Scale (CDS) in clinical recognition of dehydration in children with acute gastroenteritis.

METHODS

Six databases were searched for diagnostic accuracy studies in which population were children aged 1 to 36 months with acute gastroenteritis; index test was the CDS; and reference test was post-illness weight gain.

RESULTS

Three studies involving 360 children were included. Limited evidence showed that in high-income countries the CDS provides strong diagnostic accuracy for ruling in moderate and severe (>6%) dehydration (positive likelihood ratio 5.2-6.6), but has limited value for ruling it out (negative likelihood ratio 0.4-0.55). In low-income countries, the CDS has limited value either for ruling moderate or severe dehydration in or out. In both settings, the CDS had limited value for ruling in or out dehydration <3% or dehydration 3% to 6%.

CONCLUSION

The CDS can help assess moderate to severe dehydration in high-income settings. Given the limited data, the evidence should be viewed with caution.

The BUDDY (Bedside Ultrasound to Detect Dehydration in Youth) study

Background

Prior research suggests that the ratio of the ultrasound-measured diameter of the inferior vena cava to the aorta correlates with the level of dehydration in children. This study was designed to externally validate this and to access the accuracy of the ultrasound measured inspiratory IVC collapse and physician gestalt to predict significant dehydration in children in the emergency department.

Methods

We prospectively enrolled a non-consecutive cohort of children ≤18 years old. Patient weight, ultrasound measurements of the IVC and Ao, and physician gestalt were recorded. The percent weight change from presentation to discharge was used to calculate the degree of dehydration. A weight change of ≥5% was considered clinically significant dehydration. Receiver operating characteristic (ROC) curves were constructed for each of the ultrasound measurements and physician gestalt. Sensitivity (SN) and specificity (SP) were calculated based on previously established cutoff points of the IVC/Ao ratio (0.8), the IVC collapsibility index of 50%, and a new cut off point of IVC collapsibility index of 80% or greater. Intra-class correlation coefficients were calculated to assess the degree of inter-rater reliability between ultrasound observers.

Results

Of 113 patients, 10.6% had significant dehydration. The IVC/Ao ratio had an area under the ROC curve (AUC) of 0.72 (95% CI 0.53 to 0.91) and, with a cutoff of 0.8, produced a SN of 67% and a SP of 71% for the diagnosis of significant dehydration. The IVC collapsibility index of 50% had an AUC of 0.58 (95% CI 0.44 to 0.72) and, with a cutoff of 80% collapsibility, produced a SN of 83% and a SP of 42%. The intra-class correlation coefficient was 0.83 for the IVC/Ao ratio and 0.70 for the IVC collapsibility. Physician gestalt had an AUC of 0.61 (95% CI 0.44 to 0.78) and, with a cutoff point of 5, produced a SN of 42% and a SP of 65%.

Conclusions

The ultrasound-measured IVC/Ao ratio is a modest predictor of significant dehydration in children. The inspiratory IVC collapse and physician gestalt were poor predictors of the actual level of dehydration in this study.

Comparison of clinical and biochemical markers of dehydration with the clinical dehydration scale in children: a case comparison trial

Background

The clinical dehydration scale (CDS) is a quick, easy-to-use tool with 4 clinical items and a score of 1–8 that serves to classify dehydration in children with gastroenteritis as no, some or moderate/severe dehydration. Studies validating the CDS (Friedman JN) with a comparison group remain elusive. We hypothesized that the CDS correlates with a wide spectrum of established markers of dehydration, making it an appropriate and easy-to-use clinical tool.

Methods

This study was designed as a prospective double-cohort trial in a single tertiary care center. Children with diarrhea and vomiting, who clinically required intravenous fluids for rehydration, were compared with minor trauma patients who required intravenous needling for conscious sedation. We compared the CDS with clinical and urinary markers (urinary electrolytes, proteins, ratios and fractional excretions) for dehydration in both groups using receiver operating characteristic (ROC) curves to determine the area under the curve (AUC).

Results

We enrolled 73 children (male = 36) in the dehydration group and 143 (male = 105) in the comparison group. Median age was 32 months (range 3–214) in the dehydration and 96 months (range 2.6-214 months, p < 0.0001) in the trauma group. Median CDS was 3 (range 0–8) within the dehydration group and 0 in the comparison group (p < 0.0001). The following parameters were statistically significant (p < 0.05) between the comparison group and the dehydrated group: difference in heart rate, diastolic blood pressure, urine sodium/potassium ratio, urine sodium, fractional sodium excretion, serum bicarbonate, and creatinine measurements. The best markers for dehydration were urine Na and serum bicarbonate (ROC AUC = 0.798 and 0.821, respectively). CDS was most closely correlated with serum bicarbonate (Pearson r = -0.3696, p = 0.002).

Conclusion

Although serum bicarbonate is not the gold standard for dehydration, this study provides further evidence for the usefulness of the CDS as a dehydration marker in children.

Trial registration

Registered at ClinicalTrials.gov (NCT00462527) on April 18, 2007.

External validation and comparison of three pediatric clinical dehydration scales

Objective

To prospectively validate three popular clinical dehydration scales and overall physician gestalt in children with vomiting or diarrhea relative to the criterion standard of percent weight change with rehydration.

Methods

We prospectively enrolled a non-consecutive cohort of children ≤ 18 years of age with an acute episode of diarrhea or vomiting. Patient weight, clinical scale variables and physician clinical impression, or gestalt, were recorded before and after fluid resuscitation in the emergency department and upon hospital discharge. The percent weight change from presentation to discharge was used to calculate the degree of dehydration, with a weight change of ≥ 5% considered significant dehydration. Receiver operating characteristics (ROC) curves were constructed for each of the three clinical scales and physician gestalt. Sensitivity and specificity were calculated based on the best cut-points of the ROC curve.

Results

We approached 209 patients, and of those, 148 were enrolled and 113 patients had complete data for analysis. Of these, 10.6% had significant dehydration based on our criterion standard. The Clinical Dehydration Scale (CDS) and Gorelick scales both had an area under the ROC curve (AUC) statistically different from the reference line with AUCs of 0.72 (95% CI 0.60, 0.84) and 0.71 (95% CI 0.57, 0.85) respectively. The World Health Organization (WHO) scale and physician gestalt had AUCs of 0.61 (95% CI 0.45, 0.77) and 0.61 (0.44, 0.78) respectively, which were not statistically significant.

Conclusion

The Gorelick scale and Clinical Dehydration Scale were fair predictors of dehydration in children with diarrhea or vomiting. The World Health Organization scale and physician gestalt were not helpful predictors of dehydration in our cohort.