Which clinical signs predict severe illness in children less than 2 months of age in resource poor countries?

Abstract

Aims 8.8 million children under the age of 5 die worldwide each year and neonatal mortality contributes 4 million of these deaths. 99% of neonatal deaths occur in low and middle income countries. Identifying clinical signs which indicate severe illness in this age group is vital so that infants requiring urgent hospital referral and treatment are detected early. The WHO Integrated Management of Childhood Illness (IMCI) divides children into three age groups: 0–6 days, 7–59 days and 2–59 months. Current guidelines for infants less than 1 week of age are based on a small pool of evidence. This review was conducted focusing on all infants less than 2 months of age to help provide evidence for a referral checklist for sick neonates less than 1 week of age and allow existing IMCI guidelines to be improved. Methods Electronic databases and relevant websites were searched using a specified search strategy. Citations which were eligible focused on clinical signs indicating severe illness in infants less than 2 months of age living in resource poor countries. Relevant papers were critically appraised and data was analysed. Results 10 full text articles were applicable to the research question and predefined inclusion criteria. All studies were prospective cohorts, two of which were multicentre. Studies predominately focused on ‘severe illness’ as an outcome measure but mortality and infection were also used. Key clinical predictors of severe illness in infants less than 2 months of age were found to be: difficulty feeding, movement only when stimulated, temperature <35.5°C or ≥37.5°C, respiratory rate ≥60/min, severe chest indrawing and history of convulsions. Conclusions An algorithm to identify severe illness could encompass all infants under 2 months of age, providing jaundice is included for those infants in the first week of life. Current IMCI guidelines may be simplified to accommodate these changes. Combining key clinical signs gives a sensitive and specific approach to allow early identification of seriously ill infants. This, used in conjunction with education and improved implementation of algorithms, could help tackle the Millennium Development Goal of reducing childhood mortality by two thirds of the 1990 level by 2015.

Direct estimates of cause-specific mortality fractions and rates of under-five deaths in the northern and southern regions of Nigeria by verbal autopsy interview

“…The expert algorithms for the neonatal and 1–59 month causes of death were based on those developed by verbal autopsy researchers for prior VA validation studies [ 24 ] [ 25 ] [ 26 ] [ 27 ] [ 28 ], further consultation and a literature review to identify illness signs and symptoms commonly associated with particular neonatal and child illnesses [ 29 ] [ 30 ] [ 31 ] [ 32 ]. Hierarchies were developed for neonatal and child diagnoses to select the EAVA primary cause of death for each child from among all possible co-morbidities identified by the algorithms.…”

Clinical algorithms for the identification of sick newborns in community‐based settings

“…Therefore, clinical algorithms need to be specifically studied in this time period. Furthermore, the aetiologies for early newborn death differ from later time periods (31) and may also differ in the setting of high prevalence of other disease such as HIV and malaria (14). Finally, these algorithms also need to identify infants early enough for transfer and/or treatment rather than infants who will die when initiation of treatment is too late.…”

A Study of the Clinico-Bacteriological Profile of Infants Aged 29-59 Days Suffering from Very Severe Disease According to WHO IMCI Guideline

“…It is the time when the infants are particularly vulnerable to serious infections. 1,2,10 First week of life has the highest vulnerability to acquire serious infections which are called "early-onset neonatal sepsis", with very high mortality. 7,14 As for the neonates, the infants at the second month are also at a higher risk of mortality from infections than at later ages.…”

“…7,14 As for the neonates, the infants at the second month are also at a higher risk of mortality from infections than at later ages. 2,20 It has been suggested that immunologically naive neonates and young infants are particularly susceptible to bacterial infections because the immune system requires the first two to three months of infantile life to steadily mature up. 9,11,12,20 The Integrated Management of Childhood Illness (IMCI), formulated by WHO since 1992 has divided the under 5 children into two separate groups for the management of childhood illnesses, that is children aged 2 months up to 5 years and that of young infants below 2 months of age.…”