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Friday, January 11, 2008

Simple Checklist of Seven Clinical Signs/Symptoms could identify Sick Newborns in Developing Countries

A checklist of seven clinical signs and symptoms could help identify sick newborns, aged up to one week, with possibly life-threatening illnesses requiring immediate hospitalization. If this checklist were extensively used it could significantly reduce neonatal mortality in developing nations, according to an Article in The Lancet, this week's issue.

Approximately 4 million infants are estimated to die annually during their first month of life, 75% of them do so during their first week of life. The majority of births in low-income developing countries take place in the home, from which sick newborns are taken to health-care workers at first-level health facilities. Hence, perfecting the identification of young babies with life-threatening illnesses who need hospital referrals can have a major impact on public-health.

Developed during the 1990s, IMCI (Integrated Management of Childhood Illness) standardized the management of sick young babies up to the age of two months. However, most mortality occurs during the first week, and the IMCI does not specifically target the first week of life. The original IMCI guidelines tends to lead to too many healthy children being referred to hospital, which in developing countries places an enormous burden on weak health systems in high-mortality settings.

Dr. Martin Weber (WHO, Jakarta, Indonesia) and team from The Young Infants Clinical Signs Study Group wanted to devise a referral checklist for sick newborns during the first week of life. They also aimed to improve the current IMCI guidelines for infants aged 7 to 59 days old. They carried out a multicenter study to assess the performance of 31 simple clinical signs - when alone or in combination. First-line health workers used them to detect infants with severe illness who required hospitalization (excluding jaundice), and compared their accuracy to the judgment made by an expert pediatrician. They studied 3,177 newborns aged 0-6 days and 5,712 infants aged 7-59 days. These babies were brought in with illness to health facilities in South Africa, Pakistan, India, Ghana, Bolivia and Bangladesh.

They found 12 symptoms/signs that predicted severe illness during the first week of a baby's life:

1 - history of difficulty feeding
2 - history of convulsions
3 - lethargy
4 - movement only when stimulated
5 - respiratory rate of 60 breaths per minute or more
6 - grunting
7 - severe chest indrawing
8 - temperature of 37•5°C or more
9 - temperature below 35•5°C
10 - prolonged capillary refill
11 - cyanosis (skin, lips, tongue are bluish due to lack of oxygen)
12 - stiff limbs

According to the researchers, a decision rule which required the presence of any one sign had high sensitivity (87%) and good specificity (74%) among the babies aged 0-6 days, and an overall sensitivity of 78% and specificity of 74% among the babies aged 7-59 days.

They simplified the decision rule more on the basis of low prevalence of specific signs, or when a sign or symptom was left out of the rule which did not have an effect on sensitivity or specificity.

Consequently, the list went down to 7 sign/symptoms:

1 - history of difficulty feeding
2 - history of convulsions
3 - movement only when stimulated
4 - respiratory rate of 60 breaths per minute or more
5 - severe chest indrawing
6 - temperature of 37•5°C or more
7 - temperature below 35•5°C

This simplified decision rule had a sensitivity of 85% and a specificity of 75% in the 0-6 days age-group. For the 7-59 day age group the simplified decision rule had a sensitivity of 74% and a specifity of 79% (reasonable).

"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," the scientists concluded*.

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