INTRODUCTION Water is an essential nutrient and component in a human's body. It is 73% of the ideal weight and about 50-60% of the total weight in adults. National research suggests adequate uid intake is measured in average uid intake. (Manz et al, 2003) Mild dehydration is a loss of 1-2% of body weight and caused by an acute uid loss such as vomiting, diarrhea, and excessive physical training. These incidents affect future health and increasing the risk of urinary stones. (Armstrong et al, 2007 and Walawender et al, 2018) Poor hydration harms our health. Under some circumstances, urine concentration makes a good marker for your hydration state. It correlates to the specic gravity and osmolarity of the urine. (Guelinckx et al, 2015) Hydration state can be measured by a noninvasive method i.e. urine color scale and specic gravity. Urine color scale is validated as a hydration state marker in adults and children of 8-14 years old. By the age of 8, children can assess their urine. The awareness level in several countries is not signicantly different. In Indonesia, the awareness level is similar to France (74%), Mexico (84%), and USA (94%)(Cridge et al, 2018 and Baig et al, 2011) In 2005-2006, the research found that children and adolescents in the US did not take adequate uid recommended by the Institue of Medicine. Using osmolarity of the urine, it reveals that 60% of samples from children of 9-11 years old had inadequate hydration state, mostly caused by not drinking water, lead them to a high risk of poor hydration state. (Kenney et al, 2015) In line with Portuguese research, many children are classied as hypohydration, so increasing water and water-rich foods intake is necessary. (Padrao et al, 2016). The urine color scale has a positive correlation to the specic gravity. Dark yellow or score 4 is a predictive marker for the specic gravity of 1.030. Bongard et al, 2015) Urine specic gravity assessment with a refractometer is a notable assessment proportionate to urinalysis. The refractometer described the urine specic gravity as an indicator of soluble substance and urine concentration. In general, dark yellow urine indicates high concentration. (Bongard et al, 2015) Retrospective research in the US evaluates the correlation between urine color and specic gravity in dogs, revealed a positive correlation. However, this research has not been done on humans both in developed and developing countries. (Kavouras et al, 2016) MATERIAL AND METHOD Participant selection Students in grades 4, 5, and 6 in Singkuang and Sikapas Elementary School, district of Muara Batang Gadis, Mandailing Natal, with urine samples were included. Exclusion criteria were children with proteinuria, glucosuria, hematuria, bilirubinuria, and those whose parents refused to participate. Children with fever, liver malfunction and any chronic diseases were also excluded. Data Analysis Those who met inclusion and exclusion criteria were asked for written consent. Data retrieval was done by interview and questionnaire about age, gender, familial socioeconomic state, nutritional state, parental info such as educational background and occupation, underlying disease, 24-hour uid intake, and others that may affect urine assessment. Urine was obtained using 15ml urine pot to be examined by a RELATIONSHIP BETWEEN URINE COLOR SCALE AND URINE SPECIFIC GRAVITY TO HYDRATION STATUS IN ELEMENTARY SCHOOL STUDENT Original Research Paper Dini Arini Hasibuan Department of Pediatric, Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia Nephrology Background: Inadequate hydration state in children causes several conditions such as imbalance mood, headache, delayed cognitive function, even death. It is imperative to access the status quickly, accurately by using urine color scale and measuring the urine specic gravity. The purpose of this study is to analyze the relationship between urine color scale and urine specic gravity to hydration status in children. Method: A cross-sectional study was conducted in March 2019 in Singkuang village. The samples were elementary children from 8 to 14 years old. All samples required to ll the questionnaire and to submit the urine sample. Then, they were examined to assess hydration state. The urine was evaluated by using a urine color scale and refractometer. Bivariate analysis, chi-square, was used to analyze the determinants. The condence interval was set to 95% and P<0.05 was signicant. Result: There were 222 samples from elementary school class 4 to 6. There were 46 (20.7%) dehydrated children from a physical examination. There were 5 (2.2%) dehydrated children and 153 (65.9%) probably dehydrated children when to be assessed by urine color scale. There were 18 (8.1%), dehydrated children, when being assessed by urine specic gravity. There was no relationship between urine color scale to hydration status (P = 0.511). But the urine specic gravity was signicantly correlated to hydration status (P = 0.032) and urine color scale (P = 0.0001) Conclusion: Hydration status can be determined by evaluating urine specic gravity but not by evaluating urine color scale. ABSTRACT KEYWORDS : Urine color scale, urine specic gravity, hydration status, children. Oke Rina Ramayani* Department of Pediatric, Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia *Corresponding Author Tiangsa Sembiring Department of Pediatric, Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Munar Lubis Department of Pediatric, Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia 144 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS urine color scale. About 2 drops or 0.1 ml of urine was transferred from the transparant pot for refractometer assessment by dropping and covering it on the prism glass and measured it through the refractometer hole. Evaluation of children's hydration state was done using WHO standards. The data was written, collected, and input to the table master for further analysis with the computed statistical program. Statistical method All data were analyzed using computerized software. Characteristics of the subjects were described in the distribution of categorical data. We used a Chi-square test with p <0.05 and CI 95%. RESULTS This research enrolled 222 elementary students age 8-11. their caharacteristic data is shown in table 1. Table 1. Subject's Characteristics Pearson Chi-Square test revealed p = 0.511, so there is no signicant correlation of urine color scale to their hydration state (p>0.05, table 2) * Pearson Chi-Square Statistical test using Pearson Chi-Square revealed p = 0.032 in urine specic gravity and hydration state. There is a signicant correlation of urine specic gravity and hydration state (p<0.05, table 3) Table 3. Correlation of Urine specic gravity to hydration state * Pearson Chi-Square In table 4, Pearson Chi-Square test reveals p = 0.0001 so there is a signicant correlation of urine color scale and specic gravity (p = <0.05). Table 4. Correlation of urine color scale and specic gravity * Pearson Chi-Square DISCUSSION Urine usually have colour of either pale yellow or light yellow, and can be turn to dark yellow if the urine became concentrated. Fluid intake and few factors such as drugs, food, stress, and activity can affect urine colour. Cloudy urine can be caused by infection with pus, presence of microscopic blood cells, urinary stone, food, vaginal uid, and dehydration state. Urochrome was a pigment that gave characteristic of urine colour into yellow. Medicines and other compounds can also affect urine colour. The most common thing that can turn urine colour was blood, which can turn urine colour into pink, red, or darker. Blood in urine can be cause by diseases, and bleeding in small amount causes by drugs. Basically laboratorium nding was essential if the urine colour was checked. (Lockwood et al, 2018) In this study, there were few obstacles for assessed the colour of urine, of which there was to many that can affect urine colour. From food, drugs, infection,vaginal uid, pus caused by urinary tract infection, microscopic blood that cannot be conrmed by macroscopic ndings, direct interview, questionnaire by parents, but also needed urine laboratory to exclude factors in urine colour changing causal. Also with renal disease factors like urinary tract infection and urinary stone that needed advance examination like urinalysis, urinary tract ultrasonography, urine culture to exclude factors that effect urine colour. In 24 hours composition and concentration of urinalysis can be change, therefore, a lot of examination tipe from specimen that can be evaluated. Generally, around 10 cc urine can be used for urinalysis. Urine specimen has to be cold rst if the specimen cannot be evaluated in 2 hours after the taking, because the urine can be damaged after 2 hours, became more alkali, and causes urinalysis not longer acccurated. (Lockwood et al, 2018) Evaluation of urine specic gravity for asses the capability of kidney to concentrated and diluted the urine and the connection with plasma for comparing the weight of urine (particle) to weight of water ltration. Because urine consist of several substance like minerals and salts, the specic gravity of urine normally higher that water, usually around 1.005- 1.025, but the specic gravity of urine can increase with gain of several substance, such as protein or dehydration stated. Other things that can increase the specic gravity of urine was glucose in urine, and increased of Anti diuretic hormone (ADH), because ADH functioned to reabsorb water in tubule caused decrease of urine volume. And other several factors like trauma, stress, surgery, and drugs that can increase the secretion of ADH. Decreased of urine specic gravity can be caused by multiple factors such as diabetes insipidus where there were not or less ADH that secreted due to the damaged of pituitary glnd, so kidney produce mre urine (15-20 litre per day) with decreased of urine specic gravity. Kidney disease such as pyelonephritis and glomerulonephritis can interefere the kidney for ltered and reabsorbed water so can lower the urine specic gravity. Kidney disease such as pyelonephritis and glomerulonephritis so it can interefe the kidney to absorband reabsorbed water, so It can lower. State of kidney VOLUME-8, ISSUE-9, SEPTEMBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Characteristics Hydration Status Normal Dehydrated Sex Male 96 (54.5%) 20 (43.5%) Female Age 6-11 years old 12-16 years old Nutritional status Mild malnutrition Well nourish Overweight Obesity Frequency of drinking water (24 hours) Little (≤ 6 glasses) Adequate (7-9 glasses) Much (> 9 glasses) 80 (45.5%) 127 (72.2%) 49 (27.8%) 29 (16.5%) 110 (62.5%) 24 (13.6%) 13 (7.4%) 34 (19.3%) 118 (67%) 24 (13.7%) 26 (56.5%) 31 (67.4%) 15 (32.6%) 11 (23.9%) 31 (67.4%) 3 (6.5%) 1 (2.2%) 39 (84.8%) 7 (15.2%) 0 (0%) Urine color scale Hydration State P Value Normal Dehydrated Total Euhydrated 53 (81.5%) 12 (18.5%) 63 (100%) 0.511* Potential to dehydration 120 (78.9%) 32 (21.1%) 153 (100%) Dehydrated 3 (60%) 2 (40%) 5 (100%) Specic gravity Hydration state P value Normal Dehydrated Total Hyperhydrated 22 (84.6%) 4 (15.4%) 26 (100%) 0.032 Euhydrated 144 (80.9%) 34 (19.1%) 178 (100%) Dehydrated 10 (55.6%) 8 (44.4%) 18 (100%) Urine color scale Specic Gravity P valueHyperhydrated Euhydrated Dehydrated Euhydrated 20 (30.8%) 45 (69.2%) 0 (0%) 0.0001Potential to dehydration 6 (3.9%) 132 (86.8%) 14 (9.2%) Dehydrated 0 (0%) 1 (20%) 4 (80%) X 145GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS failure also create vary sepsic gravity between 1.007-1.001 as hypertrhropy . (Lockwood et al, 2018) This can affect study where the factor that can affect urine specic gravity such as kidney disease (pyelonephritis and glomerulonephritis), diabetes insipidus, and ADH secretion that needed for laboratory urinalisys, kultur urine, blood sample, and kidney, can exluded nw Diabetes insipidus and ADH secretion needed evaluation of investigation like urinalysis, urine culture, ADH secretion that needed further evaluation like urinalysis, and USG was needed to exluded other factor in changing of urine specic gravity. In result of study found signicant correlation between specic gravity and dehydration state in children's that maybe can be explained due to less factor that can affect urine specic gravity and several factors can be excluded with questionnaire so that in result got signicant correlation. Can be concluded that the weakness from this study was there still need to have examination that support exclusion criteria such as kidney USG, blood examination, urine culture, laboratory urinalysis to proof kidney and urinary tract disease that can affect result of urine clour scale or specic gravity. Study by Mckenzie in United stated explained that urine clour scale was usefull diagnostic to assessed hypohydation status after exercise in hot weather. Urine colour scale below 5 indicated loss of uid more than 2 % with sensitivity of 88,9% and specicity of 84,8%. This paramatre was helpful to assessed on eld when theres no equipment (for examples refractometry or osmometry ). (Shirreffs et al, 2015) Study of Shirreffs in Europe said that collection of urine for analysis can investigated and used for marking of hydration status. Osmolarity of urine can exchange with urine specic gravity as potential marker. Theres was correlation between urine colou scale to urine specic gravity and conduction force. Use eight scale and weigth shoeed that theres linear correlation between urine colour scale to urine specic gravity and urine osmolarity to estimated the hydration status. (Brewster et al, 2012) Study by Garcia in Spain for adolescent stated that validation result showed that water balance, water intake, water excretion correlated with some of important marker from hydration status, these were urine specic gravity, total weight, and urine colour scale. Recent study explained that urine specic gravity strongly correlated with urine osmolarity, so that recommended as promising marker for assessed the hydration status. Urine colour scale was subjective and depend on several factors such as drugs and food, so this marker have to combinated with other methods. (Garcia et al, 2016) Chew in Kuala Lumpur compares urine colour scale that taken with handphone to urine laboratorium, stated that there was a strong correlation between urine osmolarity to urine specic gravity and urine colour scale to assessed hydration. (Chew et al, 2018) Trabelsi in Tunisia explained that urine urine strip urine specic gravity had the same result compare the one that on laboratory to determined hydration status. In other study showed that theres a linear correlation between urine colour scale with urine specic gravity and urine osmolarity to determined hydration status. There were 6 studies that stated urine specic gravity or urine osmolarity with proof of A category as indicator to hydration status of male and athlete. (Trabelsi et al, 2017) Ersoy in Turkey studied of hydration status in male soccer with urine colour scale, urine specic gravity (laboratorium, refractometry, and strip). He stated that there was no standard for examination of hydration status, even though with plasma and urine osmolarity, but urine colour scale can be used as valid method. For additionaly, monitoring of weight when the bladder was empty, urine analysis (colour scale, urine specic gravity, and urine osmolarity) was effective methods that strongly correlated with hydration status. (Ersoy et al, 2016) Overall there was a strong correlation between urine specic gravity and urine colour scale for hydration status. There was similarity of result and validity between urine colour and urine specic gravity to urine osmolarity and plasma ormolarity. This was convenient with the result of this study that there was signicant correlation between urine specic gravity to hydration status and urine colour scale to urine specic gravity. Although there was distinction with result of study that there was no signicant correlation between urine colour scale with hydration status. 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