News Release

A single simple algorithm could be used to identify severe illness in infants aged 0–2 months

Peer-Reviewed Publication

The Lancet_DELETED

A simple checklist of seven clinical signs and symptoms could be used to identify sick neonates during the first week of life with potentially life-threatening illnesses requiring referral to hospital. Applied widely, this algorithm should have a major effect on neonatal mortality in developing countries, according to an Article in this week’s issue of The Lancet.

An estimated 4 million babies die every year during the first 28 days of life (ie, in the neonatal period)—about 75% of them die in the first week of life. Most deliveries in low-income countries still occur in the home; as a result, sick newborn children are brought to health-care workers at first-level health facilities. Thus, improving the identification of young infants with life-threatening illnesses who require referral to hospital is of major public-health importance. The original Integrated Management of Childhood Illness (IMCI) algorithms, developed during the mid-1990s, standardised the management of sick young infants aged under 2 months, but did not cover the first week of life, the period in which most mortality occurs. Furthermore, the original IMCI guidelines result in rather high referral rates, including substantial numbers of well children, which could overburden weak health systems in high-mortality settings.

Dr Martin Weber (WHO, Jakarta, Indonesia) and colleagues from The Young Infants Clinical Signs Study Group aimed to provide a referral checklist for sick neonates in the first week of life and to improve the existing IMCI guidelines for infants aged 7–59 days. They did a multicentre study to assess the performance of 31 simple clinical signs, when alone and in combination. They were used by first-line health workers to identify those with severe illness requiring hospital admission (excluding jaundice), and compared to the judgment by an expert paediatrician. 3177 children aged 0–6 days and 5712 infants aged 7–59 days brought with illness to health facilities in Bangladesh, Bolivia, Ghana, India, Pakistan, and South Africa were studied.

The researchers found 12 symptoms or signs that predicted severe illness in the first week of life: history of difficulty feeding, history of convulsions, lethargy, movement only when stimulated, respiratory rate of 60 breaths per minute or more, grunting, severe chest indrawing, temperature of 37·5°C or more or below 35·5°C, prolonged capillary refill, cyanosis, and stiff limbs. According to the authors, a decision rule requiring the presence of any one sign had high sensitivity (87%) and good specificity (74%) in the 0–6 days age-group and an overall sensitivity of 78% and specificity of 74% in the 7–59 days age-group. The authors then simplified the decision rule further on the basis of low prevalence of certain signs, or the absence of an effect on sensitivity or specificity when the sign or symptom was left out of the rule. The list was reduced to seven signs and symptoms—history of difficulty feeding, history of convulsions, movement only when stimulated, respiratory rate of 60 breaths per minute or more, severe chest indrawing, temperature of 37·5°C or more or below 35·5°C. In the 0–6 days age-group, this simplified decision rule had a sensitivity of 85% and a specificity of 75%. The seven signs also did reasonably well in the 7–59 days age-group (sensitivity 74% and specificity 79%).

The authors conclude: “Our findings have important implications for the adaptation and implementation of IMCI guidelines in countries. A single IMCI algorithm for 0–2-month-old infants based on the findings of this study with a short list of signs is much easier to teach and remember by health workers. It would have a substantially higher specificity than the existing algorithm, thus reducing over-referral.”*

In an accompanying Comment, Professor Franco Simini, Universidad de la República, Uruguay says: “If the Study Group’s score is used, existing services will not be overburdened, but mortality, or its proxy indicators will probably remain unchanged because most infants, those labelled at low risk, will still have to face the consequences of not having access to the best available care…lower mortality figures will be reached only if all patients are treated according to the best available standards, with constant and easy access to higher-level facilities and prompt referral as soon as indicated.”

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Dr Martin Weber, WHO, Jakarta, Indonesia. T) +62 21 520 43 49 ext 35 WeberM@who.or.id

Comment Professor Franco Simini, Universidad de la República, Uruguay.
T) +598 2 487 2929 simini@fing.edu.uy

Notes to Editors

* Quote directly from author and cannot be found in text of article.


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