PROVIDENCE – While the domestic health care sector is rife with mind-numbing acronyms, one new acronym, DHAKA, may be a lifesaving tool. DHAKA, which stands for Dehydration: Assess Kids Accurately, assesses the severity of dehydration in children in low-income countries.
“The DHAKA score is the first tool for assessing dehydration in [children] to be derived and validated in a developing world setting, where the vast majority of childhood diarrhea and deaths occur each year,” Dr. Adam Levine, associate professor of emergency medicine at The Warren Alpert School of Medicine at Brown University, told Providence Business News, noting that the DHAKA study is also the largest study ever assessing dehydration in children. Looking at DHAKA from an evidence-based medicine point of view, it is better than anything else out there, Levine said.
Each year, more than 9 million children die from preventable causes, mostly from dehydration, routine infections or from vaccine-preventable diseases, and more than 3 million infants die from dehydrating diseases, according to the United Nations Educational, Scientific and Cultural Organization.
Levine and his colleagues, including a team from the International Centre for Diarrhoeal Disease Research in Dhaka, Bangladesh, established the DHAKA score in 2014. After analyzing the cases of 770 children with diarrhea from cholera and other intestinal infections, they statistically determined which clinical signs upon a patient’s intake best predict dehydration severity. They identified four symptoms that a nurse or physician could readily and rapidly observe to make an accurate diagnosis:
• General appearance: Is the child restless, irritable, lethargic or unconscious?
• Breathing: Is it normal or deep?
• Skin pinch: After a pinch, does skin snap right back, respond slowly or very slowly?
• Tears: Does the child produce a normal volume of tears, less than normal or none at all?
In 2015, Levine and his colleagues returned to Bangladesh to compare DHAKA and the current standard – the World Health Organization’s Integrated Management of Childhood Illness – with 496 previously untested children; DHAKA performed significantly better than did IMCI. Nurses employed both methodologies when new patients arrived, the university reported. The DHAKA score showed significant accuracy in identifying the dehydration status – none, moderate or severe – of each child.
Asked whether DHAKA has any relevance in the United States, he added, “While it may also prove accurate and reliable in developed world settings like the United States, it should first be tested in [such] settings. There are many differences in both the types of diarrhea experienced by children in developing countries versus developed countries and also in provider experience that could affect the accuracy and reliability of the DHAKA score.”
Levine, a Lifespan physician and lead author of the DHAKA study published in The Lancet Global Health, explained that continuously improving these diagnostic methods is critically important. Hospitals or clinics with extremely limited treatment resources – such as intravenous fluids and hospital beds – should conserve those resources for the most critically dehydrated children, Levine added. Conserving resources is only part of the issue; over-treating children with IV medications who are not severely dehydrated can cause seizures or breathing problems. Oral medications can effectively treat children with moderate dehydration.
DHAKA hasn’t yet earned WHO’s endorsement as a new diagnostic standard for clinics with limited resources, such as those in Bangladesh and other poverty-stricken nations. To that end, Levine plans to return to Bangladesh this spring – cholera is prevalent in Bangladesh in spring and fall – to evaluate whether rural clinics’ providers, who lack the training and expertise that providers in Dhaka have, can use DHAKA accurately.
