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Stool frequency recording in severe acute malnutrition ('StoolSAM'); an agreement study comparing maternal recall
Wieger Voskuijl1,2, Isabel Potani3, Robert Bandsma4
1Department of Pediatrics & Child Health, the College of Medicine, University of Malawi, Blantyre, Malawi. w.p.voskuijl@amc.nl.
Insights
Maternal recall is unreliable for assessing diarrhoea in children with severe acute malnutrition (SAM). Directly observed diaper methods are more accurate for determining diarrhoea incidence in SAM patients.
Area of Science:
- Pediatrics
- Global Health
- Clinical Research
Background:
- Undernutrition, including severe acute malnutrition (SAM), contributes to approximately 50% of deaths in children under five.
- Diarrhoea is a significant factor in these child mortality cases.
- Current diagnosis of diarrhoea often relies on maternal recall of stool frequency, which may be inaccurate.
Purpose of the Study:
- To compare the accuracy of maternal recall versus direct observation of stool frequency in children with complicated SAM.
- To determine if maternal recall is equivalent to a gold standard method for assessing diarrhoea in this population.
Main Methods:
- The study involved children aged 5-59 months admitted with SAM at a Nutritional Rehabilitation Unit in Malawi.
- Stool frequency was recorded for two days using both next-day maternal recall and a gold standard method of direct observation by healthcare workers using diapers every 2 hours.
- Guardians' preferences and education levels were also assessed post-study.
Main Results:
- There was poor agreement between maternal recall and the directly observed diaper method.
- Sensitivity for detecting diarrhoea was low with maternal recall (75% on day 1, 56% on day 2), though specificity was higher (>80%).
- Discrepancies increased with higher stool frequencies, and the methods were found to be non-equivalent based on pre-specified limits of agreement. Most caregivers preferred the diaper method.
Conclusions:
- Maternal recall is not an equivalent method to direct observation for assessing stool frequency in children with SAM.
- Directly observed diaper methods are recommended for accurate determination of diarrhoea incidence/prevalence in SAM patients, especially in research settings.
- Accurate diarrhoea assessment is crucial for managing SAM and reducing child mortality.
Background:
Approximately 50% of the deaths of children under the age of 5 can be attributed to undernutrition, which also encompasses severe acute malnutrition (SAM). Diarrhoea is strongly associated with these deaths and is commonly diagnosed solely based on stool frequency and consistency obtained through maternal recall. This trial aims to determine whether this approach is equivalent to a 'directly observed method' in which a health care worker directly observed stool frequency using diapers in hospitalised children with complicated SAM.
Methods:
This study was conducted at 'Moyo' Nutritional Rehabilitation Unit, Queen Elizabeth Central Hospital, Malawi. Participants were children aged 5-59 months admitted with SAM. We compared 2 days of stool frequency data obtained with next-day maternal-recall versus a 'gold standard' in which a health care worker observed stool frequency every 2 h using diapers. After study completion, guardians were asked their preferred method and their level of education.
Results:
We found poor agreement between maternal recall and the 'gold standard' of directly observed diapers. The sensitivity to detect diarrhoea based on maternal recall was poor, with only 75 and 56% of diarrhoea cases identified on days 1 and 2, respectively. However, the specificity was higher with more than 80% of children correctly classified as not having diarrhoea. On day 1, the mean stool frequency difference between the two methods was -0.17 (SD; 1.68) with limits of agreement (of stool frequency) of -3.55 and 3.20 and, similarly on day 2, the mean difference was -0.2 (SD; 1.59) with limits of agreement of -3.38 and 2.98. These limits extend beyond the pre-specified 'acceptable' limits of agreement (±1.5 stool per day) and indicate that the 2 methods are non-equivalent. The higher the stool frequency, the more discrepant the two methods were. Most primary care givers strongly preferred using diapers.
Conclusions:
This study shows lack of agreement between the assessment of stool frequency in SAM patients using maternal recall and direct observation of diapers. When designing studies, one should consider using diapers to determining diarrhoea incidence/prevalence in SAM patients especially when accuracy is essential.
Trial Registration Number:
ISRCTN11571116 (registered 29/11/2013).
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