- Dehydration due to
diarrhea is one of the leading cause for infant and child mortality in
- Newly developed DHAKA score to assess
dehydration in children has shown very good accuracy, sensitivity and
- DHAKA score helps pick out cases of severe
dehydration in whom the limited resources can be used.
- Mild to moderate
dehydration can be treated with oral rehydration therapy (ORT) at home.
Why Is It Important to Diagnose Dehydration
Dehydration occurring due to diarrhea
is one of the leading causes of infant mortality in the
developing countries. It is
important to recognize a severely dehydrated child in the midst of seeing
several cases on a busy day, and institute prompt treatment. It may help save many precious young lives
The Dhaka 2014 Study in Brief
This study was conducted by Dr. Adam Levine, associate
professor of emergency medicine in the Warren Alpert Medical School of Brown
was assisted by a team at the International Centre for Diarrhoeal Disease
Research in Dhaka, Bangladesh.
‘DHAKA score – helps bring down diarrheal deaths in developing countries.’
The study analyzed 771 children
with diarrhea due to various causes including cholera
and severe intestinal infections.
The aim of the study was to determine which clinical signs in
the child predicted most accurately the severity of dehydration
They zeroed in on four such symptoms
that a nurse or doctor could observe in less than two minutes
make an accurate diagnosis. These included -
- General appearance: Is the child restless or irritable, or lethargic
Breathing: Is it normal or
Skin pinch: After a pinch, does skin -
- snap right back
- or very slowly?
Tears: Does the child
produce a normal volume, less than normal or none at all
symptom score aptly named the DHAKA
(after the capital of Bangladesh) stands for Dehydration Assess
Signs and Symptoms of Severe Dehydration in Children
The usual described symptoms of severe dehydration include -
shallow breathingMarked thirstDry Skin, mouth and mucous membranesSunken
eyesNo tears while cryingChild
extremely sleepy or irritableDry and shrivelled skin with
loss of elasticity; does not bounce back when pinchedVery
less or no urine at all; urine extremely dark colouredSunken
fontanels in infantsLow blood pressureRapid
and thready pulseOccasionally delirium or comaFever
Complications of Severe Dehydration in Children
Some of these can be fatal -
brainSeizures due to electrolyte imbalancesShock due to decreased blood volumeRenal failureComa
Results of the Dhaka
analyzed to see how predictive they were of dehydration severity, the tool
scored well. On an overall measure of accuracy called AUC, which ranges from 0
to 1, the DHAKA score rated a 0.8
for severe dehydration. The score's sensitivity,
on a percentage scale, was 83 percent
for severe dehydration.
This study also retrospectively compared the admission weight and the
post-rehydration weight and calculated the percent weight gain
that the results correlated perfectly with percent volume loss.
It is now the most tested method
over the current standard
, the World Health Organization's Integrated
Management of Childhood Illness (IMCI) guidelines.
Results of Validation
Studies Conducted in 2015
Dr Levine returned to Dhaka in 2015 to validate the DHAKA score
its predictive value with an entirely new population of 496 patients.
This study was carried out to determine whether the scoring method
would work for any group of patients
, not just the ones from whom it was
derived in the 2014 study.
Nurses employed both the DHAKA score and IMCI
algorithm when new patients arrived.
On a statistical scale of accuracy,
where 0.5 is no better than chance and 1 is
perfect, DHAKA rated 0.82 while IMCI
Why the Dhaka Study
and DHAKA Score are Significant
This is the first score to be derived and validated in a low-income country setting
where most diarrheal epidemics occur.
Also, the DHAKA study is the largest study ever of dehydration
assessment of kids
anywhere, with over 1200 children studied including both
the derivation and validation studies.
Final Study Planned
Dr Levine plans to return again to Dhaka in
the spring of 2016. That is the time of the year when the scourge of cholera
attacks Bangladesh every year.
This time, he plans to test it in rural
clinics of Bangladesh. He plans to determine if the DHAKA scoring is simple
enough to use in the rural clinics where there isn't the same degree of
training and experience as at the center in Dhaka.
If the study proves successful, Dr Levine hopes to earn the WHO's endorsement to use
DHAKA as the new diagnostic standard in clinics low on resources
and high on caseloads.