Improving management of dehydration in children younger than 5 years in low-and-middle-income countries
Authors: Shally Awasthi
Journal: The Lancet Global Health (2016)

Globally, diarrhoea is the second most common cause of death in children younger than 5 years.1Diarrhoeal diseaseFactsheet N0330.http://www.who.int/mediacentre/factsheets/fs330/en/Date: April 2013Google Scholar About 1·2 billion episodes of diarrhoea occur annually worldwide, resulting in roughly 760 000 deaths in children. WHO defines diarrhoea as more than three loose or liquid stools per day.1Diarrhoeal diseaseFactsheet N0330.http://www.who.int/mediacentre/factsheets/fs330/en/Date: April 2013Google Scholar Diarrhoea could be acute watery (lasting for several hours or days as occurs in cholera cases), acute bloody (also known as dysentery), or persistent (lasting for 14 or more days).1Diarrhoeal diseaseFactsheet N0330.http://www.who.int/mediacentre/factsheets/fs330/en/Date: April 2013Google Scholar Acute watery diarrhoea results in dehydration, which can cause death.2Santosham M Chandran A Fitzwater S et al.Progress and barriers for the control of diarrhoeal disease.Lancet. 2010; 376: 63-67Summary Full Text Full Text PDF PubMed Scopus (161) Google Scholar However, death is preventable in most cases by the use of oral rehydration solutions or intravenous fluids, depending on its severity. To prevent a fatal outcome, diarrhoea should be recognised, dehydration should be categorised, and appropriate therapy should be initiated according to the WHO Integrated Management of Childhood Illness (ICMI) guidelines.3Pocket Book of Hospital Care for Children: Guidelines for the management of common childhood illnesses. 2nd edn. World Health Organization, Geneva2013Google Scholar In The Lancet Global Health, Adam Levine and colleagues developed a new clinical score for assessing diarrhoea in the Dehydration: Assessing Kids Accurately (DHAKA) study done in Dhaka, Bangladesh. This new clinical score was developed and internally validated and recommended for use for assessing dehydration in children with acute diarrhoea in a low-income country.4Levine AC Glavis-Bloom J Modi P et al.Empirically derived dehydration scoring and 18 decision tree models for children with diarrhoea: assessment and internal validation in a 19 prospective cohort study in Dhaka, Bangladesh.Glob Health Sci Pract. 2015; 3: 405-418Crossref PubMed Scopus (20) Google Scholar The DHAKA score assesses general appearance, tears, skin turgor, and respirations (deep or not). The maximum score was 12 and a score of 4 or more was deemed as severe dehydration and 1 or less was deemed as no dehydration. Levine and colleagues have externally validated the score prospectively in a random sample of 496 children in Bangladesh.5Levine AC Glavis-Bloom J Modi P et al.External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study.Lancet Glob Health. 2016; (published online Aug 22.)http://dx.doi.org/10.1016/S2214-109X(16)30150-4Google Scholar They validated the DHAKA score and dehydration grading with the IMCI approach against a gold standard, which was weight gained after rehydration in a child with acute watery diarrhoea, with children with severe dehydration gaining more than 9% of their bodyweight, those with some dehydration gaining 3–9% of their bodyweight, and those with no dehydration gaining less than 3% of their bodyweight. The IMCI assessment relies on general appearance, ability to drink, skin pinch, and sunken eyes but does not include numerical scoring. Adam Levine and colleagues have stated that because physicians and nurses see several cases of diarrhoea, categorising dehydration with numerical values, as done with the DHAKA score but not with the IMCI algorithm, might increase inter-rater reliability and perhaps result in better management. However, some questions remain unanswered with the DHAKA score. An increase in DHAKA score was found to result in an increase in specificity increases at the cost of sensitivity. The IMCI score does well across all ages in terms of sensitivity and specificity5Levine AC Glavis-Bloom J Modi P et al.External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study.Lancet Glob Health. 2016; (published online Aug 22.)http://dx.doi.org/10.1016/S2214-109X(16)30150-4Google Scholar and is easy to remember with the help of flow charts. By contrast, the DHAKA score uses a numerical system, which might be difficult to remember. The DHAKA score does not have a clear cutoff to indicate severe, some, or no dehydration. The DHAKA score has not been validated in under-nourished children or those with hyponatraemia or hypernatraemia dehydration. In the study by Levine and colleagues, the same individual applied both the DHAKA score and IMCI algorithm on a child, hence systematic bias might exist. The IMCI algorithms have been developed and endorsed by WHO in the 1990s and most low-income and middle-income countries are using them. The IMCI strategy algorithms are not only for diarrhoea but also other common childhood illnesses, such as pneumonia. These countries have invested heavily in training their health-care staff to use IMCI algorithms. A Cochrane systematic review6Gera T Shah D Garner P Richardson M Sachdev HPS Integrated Management of Childhood Illness (IMCI) Strategy for children under five.Cochrane Database Syst Rev. 2016; (published online June 22.)https://doi.org/10.1002/14651858.CD010123.pub2Crossref Scopus (83) Google Scholar assessed the effect of programmes that have used WHO's IMCI strategy. Four studies were included that were done in Tanzania, Bangladesh, and India. The review concluded that the IMCI strategy might lead to fewer deaths in children younger than 5 years of age (low certainty evidence). Hence, almost three decades after the development of IMCI strategy, a need to improve management of acute watery diarrhoea exists. In this context, development of new scores, like the DHAKA score, and diarrhoea management algorithms are appropriate. However, the external validation of the DHAKA score5Levine AC Glavis-Bloom J Modi P et al.External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study.Lancet Glob Health. 2016; (published online Aug 22.)http://dx.doi.org/10.1016/S2214-109X(16)30150-4Google Scholar is not likely to have a significant effect on practice at this point in time. There is scope for further external validation of the DHAKA score in other low and middle-income countries and research into quantifying the level of dehydration to improve management and survival of infants and children with acute watery diarrhoea. This online publication has been corrected. The corrected version first appeared at thelancet.com on Nov 9, 2016 This online publication has been corrected. The corrected version first appeared at thelancet.com on Nov 9, 2016 I declare no competing interests. External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort studyThe DHAKA score is the first clinical tool for assessing dehydration in children with acute diarrhoea to be externally validated in a low-income country. Further validation studies in a diverse range of settings and paediatric populations are warranted. Full-Text PDF Open AccessCorrection to Lancet Glob Health 2016; 4: e674–75Awasthi S. Improving management of dehydration in children younger than 5 years in low-and-middle-income countries. Lancet Glob Health 2016; 4: e674–75—In this Comment (October, 2016) the last sentence of the second paragraph should have read: “The IMCI assessment relies on general appearance, ability to drink, skin pinch, and sunken eyes…”. The third, fourth, and fifth sentences of the third paragraph should have been deleted. The penultimate sentence of the third paragraph should have read: “The DHAKA score has not been validated in under-nourished children or those with hyponatraemia or hypernatraemia dehydration.” These corrections were made on Nov 9, 2016. Full-Text PDF Open Access