Integrated Management Of Childhood Illness Guidelines Research Articles

Implication of the 2014 World Health Organization Integrated Management of Childhood Illness Pneumonia Guidelines with and without pulse oximetry use in Malawi: A retrospective cohort study.

Under-5 pneumonia mortality remains high in low-income countries. In 2014 the World Health Organization (WHO) advised that children with chest indrawing pneumonia, but without danger signs or peripheral oxygen saturation (SpO 2) < 90% be treated in the community, rather than hospitalized. In Malawi there is limited pulse oximetry availability. Secondary analysis of 13,413 under-5 pneumonia cases in Malawi. Pneumonia associated case fatality ratios (CFR) were calculated by disease severity under the assumptions of the 2005 and 2014 WHO Integrated Management of Childhood Illness (IMCI) guidelines, with and without pulse oximetry. We investigated if pulse oximetry readings were missing not at random (MNAR). The CFR of patients classified as having non-severe pneumonia per the 2014 IMCI guidelines doubled under the assumption that pulse oximetry was not available (1.5% without pulse oximetry vs 0.7% with pulse oximetry, P<0.001). When 2014 IMCI guidelines were applied with pulse oximetry and a SpO 2 < 90% as the threshold for referral and/or admission, the number of cases meeting hospitalization criteria decreased by 70.3%. Unrecorded pulse oximetry readings were MNAR with an adjusted odds for mortality of 4.9 (3.8, 6.3), similar to that of a SpO 2 < 90%. Although fewer girls were hospitalized, female sex was an independent mortality risk factor. In Malawi, implementation of the 2014 WHO IMCI pneumonia guidelines, without pulse oximetry, will miss high risk cases. Alternatively, implementation of pulse oximetry may result in a large reduction in hospitalization rates without significantly increasing non-severe pneumonia associated CFR if the inability to obtain a pulse oximetry reading is considered a WHO danger sign.

Perceptions of Undergraduate Medical Students Toward Integrated Management of Childhood Illness (IMCI) Pre-service Education at Sultan Qaboos University, Muscat.

Background Inconsistent evidence concerning the clinical practice implications of the Integrated Management of Childhood Illness (IMCI) pre-service education exists in the literature. The aim of this study is to assess the IMCI pre-service training perceptions of medical students, including their willingness to prospectively utilize the IMCI guidelines in clinical settings. Methods This is an observational cross-sectional study that was conducted between June 1 and August 31, 2022, at the College of Medicine and Health Sciences, Sultan Qaboos University (SQU), Muscat, Sultanate of Oman. The demographic data and IMCI pre-service education perceptions were recorded via the 10 close-ended questions. The questions focused on the student's perception of the usefulness of IMCI pre-service training in improving their knowledge, attitude, and practice (KAP) regarding childhood illnesses and how well it has enhanced their skills in dealing with sick children. SPSS Statistics version 26.0 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.) was used to analyze the data. Results A total of 196 responses were collected, with 117 of them being from female participants and the remaining 79 from male participants. Participants were subcategorized into phase 2 (n=103), phase 3A (pre-clerkship, n=45), and phase 3B (junior clerkship, n=48). At least 67.8% of 171 medical students complying with one to two training sessions intended to apply their IMCI pre-service education knowledge and skills in clinical practice and parental counseling. The medical knowledge and clinical practice skill enhancement abilities of the IMCI sessions were recognized by ≥49.7% of medical students. The student responses regarding childhood illness management (p=0.03) and holistic assessment confidence (p=0.042) varied significantly between the study phases. The IMCI pre-service skills, knowledge, and confidence levels were observed in 47.1% (phase 2), 13.2% (phase 3A), and 35.5% (phase 3B) of medical students. Similarly, 40.2% (phase 2), 23.7% (phase 3A), and 54.8% (phase 3B) of subjects believed in the IMCI pre-service training's influence on their ability to perform holistic assessments in the pediatric population. Conclusion The overall results of this study advocate the clinical practice implications, based on the positive student perceptions, of the IMCI pre-service training in SQU. Future qualitative studies should evaluate these findings with wider student populations.

Implication of the 2014 World Health Organization Integrated Management of Childhood Illness Pneumonia Guidelines with and without pulse oximetry use in Malawi: A retrospective cohort study

Background: Under-5 pneumonia mortality remains high in low-income countries. In 2014 the World Health Organization (WHO) advised that children with chest indrawing pneumonia, but without danger signs or peripheral oxygen saturation (SpO2) &lt; 90% be treated in the community, rather than hospitalized. In Malawi there is limited pulse oximetry availability. Methods: Secondary analysis of 13,413 under-5 pneumonia cases in Malawi. Pneumonia associated case fatality ratios (CFR) were calculated by disease severity under the assumptions of the 2005 and 2014 WHO Integrated Management of Childhood Illness (IMCI) guidelines, with and without pulse oximetry. We investigated if pulse oximetry readings were missing not at random (MNAR). Results: The CFR of patients classified as having non-severe pneumonia per the 2014 IMCI guidelines doubled under the assumption that pulse oximetry was not available (1.5% without pulse oximetry vs 0.7% with pulse oximetry, P&lt;0.001). When 2014 IMCI guidelines were applied with pulse oximetry and a SpO2 &lt; 90% as the threshold for referral and/or admission, the number of cases meeting hospitalization criteria decreased by 70.3%. Unrecorded pulse oximetry readings were MNAR with an adjusted odds for mortality of 4.9 (3.8, 6.3), similar to that of a SpO2 &lt; 90%. Although fewer girls were hospitalized, female sex was an independent mortality risk factor. Conclusions: In Malawi, implementation of the 2014 WHO IMCI pneumonia guidelines, without pulse oximetry, will miss high risk cases. Alternatively, implementation of pulse oximetry may result in a large reduction in hospitalization rates without significantly increasing non-severe pneumonia associated CFR if the inability to obtain a pulse oximetry reading is considered a WHO danger sign.

Risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh: a multifacility prospective cohort study

Hypoxaemic pneumonia mortality risk in low-income and middle-income countries is high in children who have been hospitalised, but unknown among outpatient children. We sought to establish the outpatient burden, mortality risk, and prognostic accuracy of death from hypoxaemia in children with suspected pneumonia in Bangladesh. We conducted a prospective community-based cohort study encompassing three upazila (subdistrict) health complex catchment areas in Sylhet, Bangladesh. Children aged 3-35 months participating in a community surveillance programme and presenting to one of three upazila health complex Integrated Management of Childhood Illness (IMCI) outpatient clinics with an acute illness and signs of difficult breathing (defined as suspected pneumonia) were enrolled in the study; because lower respiratory tract infection mortality mainly occurs in children younger than 1 year, the primary study population comprised children aged 3-11 months. Study physicians recorded WHO IMCI pneumonia guideline clinical signs and peripheral arterial oxyhaemoglobin saturations (SpO2) in room air. They treated children with pneumonia with antibiotics (oral amoxicillin [40 mg/kg per dose twice per day for 5-7 days, as per local practice]), and recommended oxygen, parenteral antibiotics, and hospitalisation for those with an SpO2 of less than 90%, WHO IMCI danger signs, or severe malnutrition. Community health workers documented the children's vital status and the date of any vital status changes during routine household surveillance (one visit to each household every 2 months). The primary outcome was death at 2 weeks after enrolment in children aged 3-11 months (primary study population) and 12-35 months (secondary study population). Primary analyses included estimating the outpatient prevalence, mortality risk, and prognostic accuracy of hypoxaemia for death in children aged 3-11 months with suspected pneumonia. Risk ratios were produced by fitting a multivariable model that regressed predefined SpO2 ranges (<90%, 90-93%, and 94-100%) on the primary 2-week mortality outcome (binary outcome) using Poisson models with robust variance estimation. We established the prognostic accuracy of WHO IMCI guidelines for death with and without varying SpO2 thresholds. Participants were recruited between Sept 1, 2015, to Aug 31, 2017. During the study period, a total of 7440 children aged 3-35 months with the first suspected pneumonia episode were enrolled, of whom 3848 (54·3%) with an attempted pulse oximeter measurement and 2-week outcome were included in our primary study population of children aged 3-11-months. Among children aged 3-11 months, an SpO2 of less than 90% occurred in 102 (2·7%) of 3848 children, an SpO2 of 90-93% occurred in 306 (8·0%) children, a failed SpO2 measurement occurred in 67 (1·7%) children, and 24 (0·6%) children with suspected pneumonia died. Compared with an SpO2 of 94-100% (3373 [87·7%] of 3848), the adjusted risk ratio for death was 10·3 (95% CI 3·2-32·3; p<0·001) for an SpO2 of less than 90%, 4·3 (1·5-11·8; p=0·005) for an SpO2 of 90-93%, and 11·4 (3·1-41·4; p<0·001) for a failed measurement. When not considering pulse oximetry, of the children who died, WHO IMCI guidelines identified only 25·0% (95% CI 9·7-46·7; six of 24 children) as eligible for referral to hospital. For identifying deaths, in children with an SpO2 of less than 90% WHO IMCI guidelines had a 41·7% sensitivity (95% CI 22·1-63·4) and 89·7% specificity (88·7-90·7); for children with an SpO2 of less than 90% or measurement failure the guidelines had a 54·2% sensitivity (32·8-74·4) and 88·3% specificity (87·2-89·3); and for children with an SpO2 of less than 94% or measurement failure the guidelines had a 62·5% sensitivity (40·6-81·2) and 81·3% specificity (80·0-82·5). These findings support pulse oximeter use during the outpatient care of young children with suspected pneumonia in Bangladesh as well as the re-evaluation of the WHO IMCI currently recommended threshold of an SpO2 less than 90% for hospital referral. Fogarty International Center of the National Institutes of Health (K01TW009988), The Bill & Melinda Gates Foundation (OPP1084286 and OPP1117483), and GlaxoSmithKline (90063241).

Antibiotic Prescription Patterns in Children Under 5 Years of Age With Acute Diarrhea in Quito-Ecuador.

Diarrheal disease remains a significant cause of child mortality, particularly in regions with limited access to healthcare and sanitation. Inappropriate practices, including unjustified medication prescriptions, pose challenges in the management of acute diarrhea (AD), especially in low- and middle-income countries. This study analyzed antibiotic prescription patterns and assessed compliance with Integrated Management of Childhood Illness (IMCI) guidelines in children under 5 with AD in the Ministry of Public Health (MOPH) Ambulatory Care Centers of Quito city, Ecuador. A cross-sectional design was used, collecting electronic health records (EHR) of patients diagnosed with AD from 21 health facilities in District 17D03. A probabilistic and stratified sampling approach was applied. Patient characteristics, prescriber characteristics, treatments, and compliance of IMCI guideline recommendations were evaluated. A stepwise logistic regression analysis examined the association between antibiotic prescription and patient and physician characteristics. A total of 359 children under 5 years of age were included, with 58.77% being girls. 85.24% of the cases of AD were attributed to gastroenteritis and colitis of infectious and unspecified origin. Amebiasis and other protozoal intestinal diseases accounted for 13.37% and 1.11% of the cases, respectively. The completion rates of recording various IMCI parameters varied; parameters such as duration of diarrhea, presence of blood in stool, and evidence of sunken eyes had high completion rates (100%, 100%, and 87.47%, respectively), while parameters like state of consciousness, presence of thirst, and type of diarrhea had low completion rates (0.28%, 0.28%, and 0.84%, respectively). None of the cases had all parameters fully recorded. Antimicrobials were prescribed in 38.72% of the cases. Children aged 3 to 5 years had higher odds of receiving antimicrobial prescription for AD (aOR: 4.42, 95% CI 2.13-9.18, P < .0001) compared to those under 1 year, after adjusting for the number of loose stools per day, gender, and age of the health professional. Variations in IMCI guideline compliance were observed, with no cases fully adhering to the guidelines. Antimicrobial prescription rates were notably high, especially among older children. Further research and specialized interventions are necessary to gain comprehensive insight into the factors underlying non-compliance with the IMCI guidelines.

Dengue algorithms integrated into the IMCI guidelines: An updated assessment in five Southeast-Asian countries.

BackgroundDengue is not included explicitly in the WHO Integrated Management of Childhood Illness (IMCI) algorithm. However, the assessment, classification and management of dengue has been incorporated into several IMCI country adaptations. We aimed to evaluate the dengue algorithms incorporated into IMCI guidelines and discuss the need for harmonization, including an extension of the age range for IMCI.MethodsThis study included three steps. First, we investigated dengue algorithms incorporated into five Southeast-Asian (Myanmar, Philippines, Vietnam, Indonesia, Cambodia) country IMCI guidelines through a desk-based analysis. Second, we conducted an expert survey to elicit opinions regarding the integration of dengue and extension of the age range in IMCI. Third, we compared our findings with data from a large multicentric prospective study on acute febrile illness.ResultsWe found considerable heterogeneity between the country specific IMCI guidelines in the dengue algorithms as well as classification schemes. Most guidelines did not differentiate between diagnostic algorithms for the detection of dengue versus other febrile illness, and warning signs for progression to severe dengue. Our expert survey resulted in a consensus to further integrate dengue in IMCI and extend the age range for IMCI guidelines beyond 5 years of age. Most of the interviewees responded that their country had a stand-alone clinical guideline for dengue, which was not integrated into the IMCI approach and considered laboratory testing for dengue necessary on day three of consecutive fever. Using data from a large multicentric study of children 5–15 years of age, we could confirm that the likelihood of dengue increased with consecutive fever days. However, a significant proportion of children (36%) would be missed if laboratory testing was only offered on the third consecutive day of fever.ConclusionsThis study supports the extension of the IMCI age range beyond 5 years of age as well as the inclusion of dengue relevant content in the algorithm. Because of the challenge of distinguishing dengue from other febrile illnesses, simple laboratory testing (e.g., full blood count) should be offered at an early stage during the course of the illness. Testing only children with consecutive fever over 3 days may lead to an underdiagnosis of dengue among those with acute febrile illness in children 5–15 years of age. In addition, specific laboratory testing for dengue should be made available to peripheral health facilities.

Evaluation of Adherence of Health-Care Workers to Integrated Management of Childhood Illness Guidelines in the Context of the Free Care Program in Burkina Faso.

To reduce child mortality in children younger than 5 years, Burkina Faso has been offering free care to this population of children since 2016. The free care program is aligned with the Integrated Management of Childhood Illness (IMCI) guidelines. Given that the number of studies that evaluated the competence of health-care workers (HCWs) during the free care program was limited, we assessed the adherence level of HCWs to the IMCI guidelines in the context of free care. This was a secondary data analysis. Data were obtained from a cross-sectional study conducted from July to September 2020 in 40 primary health-care centers and two district hospitals in the Hauts-Bassins region in Burkina Faso. Our analysis included 419 children younger than 5 years old who were consulted according to IMCI guidelines. Data were collected through direct observation using a checklist. The overall score of adherence of HCWs to IMCI guidelines was 57.8% (95% CI, 42.6-73.0). The mean adherence score of the evaluation of danger signs was 71.9% (95% CI, 58.7-85.1). The mean adherence score of following IMCI guidelines was significantly greater in boys (54.2%) compared with girls (44.6%; P < 0.001). Adherence scores of the performance of different IMCI tasks were significantly different across HCW categories. The overall adherence of HCWs to IMCI guidelines in the context of free care was greater than the adherence reported before the implementation of free care in Burkina Faso. However, this assessment needs to be performed nationwide to capture the overall adherence of HCWs to IMCI guidelines in the context of the free care program.

Higher childhood pneumonia admission threshold remains in Lao PDR: an observational study

ObjectivesWHO Integrated Management of Childhood Illness (IMCI) guidelines changed pneumonia hospitalisation criteria in 2014, which was implemented in Lao People’s Democratic Republic (Lao PDR) in 2015. We determined adherence to:...

Integrated Management of Childhood Illnesses (IMCI): a mixed-methods study on implementation, knowledge and resource availability in Malawi

BackgroundThe introduction of the WHO’s Integrated Management of Childhood Illnesses (IMCI) guidelines in the mid-1990s contributed to global reductions in under-five mortality. However, issues in quality of care have been...

Improving the Assessment and Classification of Sick Children according to the Integrated Management of Childhood Illness (IMCI) Protocol at Sanja Primary Hospital, Northwest Ethiopia: A Pre-Post Interventional Study.

Background A complete and consistent use of integrated management of childhood illness (IMCI) protocol is a strategic implementation that has been used to promote the accurate assessment and classifications of childhood illnesses, ensures appropriate combined treatment, strengthens the counseling of caregiver, and speeds up the referrals to decrease child mortality and morbidity. However, there is limited evidence about the complete and consistent use of IMCI protocol during the assessment and classifications of childhood illness in Ethiopia. Therefore, this intervention was implemented to improve the assessment and classifications of childhood illness according to the IMCI protocol in Sanja primary hospital, northwest Ethiopia. Methods A pre-post interventional study was used in Sanja primary hospital from January 01 to May 30, 2019. A total of 762 (381 for pre and 381 for postintervention) children from 2 months up to 5 years of age were involved in the study. Data were collected using a structured questionnaire prepared from the IMCI guideline, and a facility checklist was used. A five-month in-service training, weekly supportive supervision, daily morning session, and availing essential drugs and materials were done. Both the descriptive statistics and independent t-test were done. In the independent t-test, a p value of <0.05 and a mean difference with 95% CI were used to declare the significance of the interventions. Results The findings revealed that the overall completeness of the assessment was improved from 37.8 to 79.8% (mean difference: 0.17; 95% CI: 0.10-0.22), consistency of assessment with classification from 47.5 to 76.9% (mean difference: 0.34; 95% CI: 0.27-0.39), classification with treatment from 42.3 to 75.4% (mean difference: 0.35; 95% CI: 0.28-0.47), and classification with follow-up from 32.8 to 73.0% (mean difference: 0.36; 95% CI: 0.29-0.42). Conclusion The intervention has a significant improvement in the assessment and classification of childhood illness according to the IMCI protocol. Therefore, steps must be taken to ensure high quality of training, adequate supervision including the observation of health workers managing sick children during supervisory visits, and a constant supply of essential drugs and job aids for successful implementation of IMCI in the hospital and also to other facilities.

Assessing the quality of care in sick child services at health facilities in Ethiopia

BackgroundQuality of care depends on system, facility, provider, and client-level factors. We aimed at examining structural and process quality of services for sick children and its association with client satisfaction at health facilities in Ethiopia.MethodsData from the Ethiopia Service Provision Assessment Plus (SPA+) survey 2014 were used. Measures of quality were assessed based on the Donabedian framework: structure, process, and outcome. A total of 1908 mothers or caretakers were interviewed and their child consultations were observed. Principal component analysis was used to construct quality of care indices including a structural composite score, a process composite score, and a client satisfaction score. Multilevel mixed linear regression was used to analyze the association between structural and process factors with client satisfaction.ResultAmong children diagnosed with suspected pneumonia, respiratory rate was counted in 56% and temperature was checked in 77% of the cases. A majority of children (92%) diagnosed with fever had their temperature taken. Only 3% of children with fever were either referred or admitted, and 60% received antibiotics. Among children diagnosed with malaria, 51% were assessed for all three Integrated Management of Childhood Illnesses (IMCI) main symptoms, and 4% were assessed for all three general danger signs. Providers assessed dehydration in 54% of children with diarrhea with dehydration, 17% of these children were admitted or referred to another facility, and Oral Rehydration Solution was prescribed for 67% while none received intravenous fluids. The number of basic amenities in the facility was negatively associated with the clients’ satisfaction. Private facilities, when the providers had got training for care of sick children in the past 2 years, had higher client satisfaction. There was no statistical association between structure, process composite indicators and client satisfaction.ConclusionThe assessment of sick children was of low quality, with many missing procedures when comparing with IMCI guidelines. In spite of this, most clients were satisfied with the services they received. Structural and process composite indicators were not associated with client’s satisfaction. These findings highlight the need to assess other dimensions of quality of care besides structure and process that may influence client satisfaction.

'Everybody in Nigeria is a doctor…': a qualitative study of stakeholder perspectives on lay diagnosis of malaria and pneumonia in Nigeria.

Lay diagnosis is a widely used diagnostic approach for home management of common illnesses in Nigeria. This study aimed to explore the perspectives of caregivers and healthcare professionals on lay diagnosis of childhood malaria and pneumonia. Aligned to this, the study sought to explore the feasibility of training caregivers in the Integrated Management of Childhood Illness (IMCI) guidelines for improved recognition and treatment of these diseases. A qualitative study using individual face-to-face semi-structured interviews was conducted in Benin City, Nigeria. Participants included 13 caregivers with children under 5 years and 17 healthcare professionals (HPs). An inductive approach to thematic analysis was used to generate themes and analyses. Caregivers relied on lay diagnosis but recognised its limitations. The perceived severity of malaria and pneumonia significantly influenced caregivers' preference for reliance on lay diagnosis practices, health-seeking behaviour and willingness to undertake training in IMCI guidelines for home management of diseases. Safety and potential unintended misuse of medications were recognised by caregivers and HPs as the main challenges. The high level of acceptance among caregivers to receive IMCI training could help improve effective management of childhood malaria and pneumonia at the community level through early recognition and prompt treatment.

Implementation of Integrated Management of Childhood Illness Strategy's in Al Hadbaa Primary Health Care Center in Mosul City

Background: The World Health Organization (WHO) build up guidelines for the integrated management of childhood illnesses (IMCI) in the health facilities to improve the recognition and the individual management of the common reasons of death among children under the age of five. The approach used in outpatient clinical settings with restricted diagnostic and therapeutic tools. Aim of study: To assess the impact of implementation of IMCI strategy, in reducing an inappropriate prescription of antibiotics and raising vaccination coverage. Patients and methods: A cross-sectional study design was arranged, where 395 child with age from two months up to below 5 years old attending Al Hadbaa PHCC from 1st of January to 31st of March 2014 suffering from one or more of the following respiratory infection, diarrheal diseases, throat infections, ear infections and fever. The children assessed separately by two clinics, "A" non-adopting IMCI and "B" adopting IMCI guidelines, the Mc-Nemar test was applied and differences were evaluated. Results: The attendant children are 239 males and 156 females complaining from fever (39.1%), throat problems (21.4%), ear problems (12.6%), cough (11.6%), diarrhea (11.1%) and pneumonia (4.2%). The overall use of antibiotics is 66.1% in clinic "A" and 21.0% in clinic "B" with p-value 0.000. Regarding the immunization, the outcomes appear to have very high significant difference 54.1% in "A" and 75.7% in "B". Conclusion: The classification-approach to the sick child using IMCI guidelines has clear effect on decreasing an inappropriate use of antibiotics and raising number of vaccinated children, which justifying the adaptation of this strategy.

Evaluation of Application of Nutritional Status Assessment for Children Under 5 years by Using IMCI Program in a Sample of Primary Health Care Centers in Baghdad City

Background: World Health Organization (WHO) and United Nation International Children Fund (UNICEF) developed a strategy known as Integrated Management of Childhood Illness (IMCI); which aims to reduce less than five years children morbidity and mortality in developing countries.&#x0D; Objective: To assess the completion of the IMCI format status in primary health care centers, Baghdad.&#x0D; Methods: A cross sectional study with analytic element was conducted during the period from 15th of January till 15th May 2016 in selected Primary health centers in Baghdad, Iraq. The sample consists of form of child files less than 2 months and form from 2 month up to 5 years children. Classified correctively, determined follow up visits, Comparison classified of nutritional status assessment between health center and IMCI guideline.&#x0D; Result: 1400 child files were collected, 1295 from child files (2months-5year), and 105 forms from child less than 2 month. In form less than 2 months (correct classified 54.29%, incorrect 45.71%), (Determined date of follow up 13.33%, not determined 86.67%).Form from (2month-5years) (57.07% correct classified, 43.93% incorrect classified), (Determined date Follow up visit 38.38%, Not determined visit 61.62%).&#x0D; Conclusion: Impaired classification of nutritional status assessment

Addressing malnutrition among children in routine care: how is the Integrated Management of Childhood Illnesses strategy implemented at health centre level in Burundi?

BackgroundThe Integrated Management of Childhood Illness (IMCI) strategy was adopted in Burundi in 2003. Our aim was to evaluate to what extent the malnutrition component of the IMCI guidelines is implemented at health facilities level.MethodsWe carried out direct observations of curative outpatient consultations for children aged 6–59 months in 90 health centres selected randomly. We considered both the child and the health worker (HW) as units of analysis and used bivariate analysis to explore characteristics of HWs associated with tasks systematically or never performed.ResultsA total of 514 consultations carried out by 145 HWs were observed. Among the 250 children under two years, less than 30% were asked questions on breastfeeding. None of them had all seven nutrition-related questions asked to their caregivers and none of the 200 children over the age of two years had all five nutrition-related questions asked to their caregivers. Only 13 cases (3%) had all of the six examinations/tasks (weight, height/length, mid-upper arm circumference, oedema, filling in and discussing the growth curve and calculating the weight for height z-score) performed as part of their care. 393 cases (76%) reported that they had not being given any nutrition advice.With regards to HWs, among 99 of them who had received children under two, only 21 (21.2%)[14.2–30.5%) systematically asked the question regarding ‘ongoing breastfeeding’.Only 56 (38.6%)[31–46.9%] weighed or discussed the weight taken prior the consultation for each child they reviewed, only 38 (26.2%)[19.6–34.1%] measured the height/length or discussed it for each child reviewed and 23 (15.9%)[10.7–22.8%] performed (systematically?) the WHZ-score.More than 50% never gave nutrition advices to any child reviewed.HWs who daily manage severe acute malnutrition were the most likely to systematically ask the question regarding ‘ongoing breastfeeding’ and to perform a ‘weight examination’. Those who had not received supervision visit on the topic of malnutrition predominantly never performed a ‘weight examination’. The ‘height/length’ examination’ was predominantly performed by female HWs and those who have ‘contract with the government.ConclusionThis study has found poor compliance by HWs to IMCI in Burundi. This indicates that a substantial proportion of children do not receive early and appropriate care, especially that pertaining to malnutrition. This alarming situation calls for strong action by actors committed to child health in the country.Trial registrationClinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).

Emerging Resistance to Empiric Antimicrobial Regimens for Pediatric Bloodstream Infections in Malawi (1998-2017).

BackgroundThe adequacy of the World Health Organization’s Integrated Management of Childhood Illness (IMCI) antimicrobial guidelines for the treatment of suspected severe bacterial infections is dependent on a low prevalence of antimicrobial resistance (AMR). We describe trends in etiologies and susceptibility patterns of bloodstream infections (BSI) in hospitalized children in Malawi.MethodsWe determined the change in the population-based incidence of BSI in children admitted to Queen Elizabeth Central Hospital, Blantyre, Malawi (1998–2017). AMR profiles were assessed by the disc diffusion method, and trends over time were evaluated.ResultsA total 89643 pediatric blood cultures were performed, and 10621 pathogens were included in the analysis. Estimated minimum incidence rates of BSI for those ≤5 years of age fell from a peak of 11.4 per 1000 persons in 2002 to 3.4 per 1000 persons in 2017. Over 2 decades, the resistance of Gram-negative pathogens to all empiric, first-line antimicrobials (ampicillin/penicillin, gentamicin, ceftriaxone) among children ≤5 years increased from 3.4% to 30.2% (P < .001). Among those ≤60 days, AMR to all first-line antimicrobials increased from 7.0% to 67.7% (P < .001). Among children ≤5 years, Klebsiella spp. resistance to all first-line antimicrobial regimens increased from 5.9% to 93.7% (P < .001).ConclusionsThe incidence of BSI among hospitalized children has decreased substantially over the last 20 years, although gains have been offset by increases in Gram-negative pathogens’ resistance to all empiric first-line antimicrobials. There is an urgent need to address the broader challenge of adapting IMCI guidelines to the local setting in the face of rapidly-expanding AMR in childhood BSI.

Comparative Study Between Integrated Management of Childhood Illness Guidelines and Traditional Methods in Management of Acute Pharyngitis among Children Under Five Years in Zagazig District, Egypt

Background: Pharyngitis is one of the most frequently faced pediatric problems with serious complications in primary care. Objective(s): To compare between Integrated Management of Childhood Illness (IMCI) guidelines and traditional management concerning diagnosis and antibiotic prescription for acute pharyngitis in children less than 5 years, as well as to determine validity of IMCI guidelines in diagnosis of acute pharyngitis by comparing their results to throat culture as a golden standard. Methods: A comparative cross-sectional study was conducted in one primary health care center and one unit where IMCI guidelines were implemented; as well as one center and one unit where traditional management of acute pharyngitis was implemented in Zagazig district, on 343 children under five years complaining of sore throat or difficult feeding. About 86 children were randomly selected from each health facility during the period of first of January until end of June 2017. Doctor’s clinical diagnosis and antibiotic prescription were reported for all children, while throat swabs were taken from children managed according to IMCI guidelines for bacterial culture. Results: According to IMCI, only 11 % of children were diagnosed as bacterial pharyngitis, antibiotic prescription was significantly lower among those managed according to IMCI compared to traditional methods (11% & 96.5% respectively, P<0.001). However, throat culture revealed that 28.5% of children managed according to IMCI guidelines had positive bacterial growth. Sensitivity of IMCI guidelines to detect bacterial cases of pharyngitis was only 36.7 % and Positive Predictive Value (PPV) was 94.7%, while their specificity to exclude bacterial and detect viral infection was about 99.2% and the Negative Predictive Value (NPV) was 79.7%. Conclusion: Application of IMCI guidelines is considered valuable in prevention of antibiotic abuse. However, the sensitivity of IMCI guidelines to detect bacterial pharyngitis was 36.7%. Key words: integrated management of childhood illness guidelines, validity, acute pharyngitis

Are children presenting with non-IMCI complaints at greater risk for suboptimal screening? An analysis of outpatient visits in Afghanistan.

To determine if children presenting without complaints related to the Integrated Management of Childhood Illness (IMCI) are at greater risk for suboptimal screening for IMCI conditions. Cross-sectional study. Thirty-three provinces in Afghanistan. Observation of 3072 sick child visits selected by systematic random sampling. A 10 point IMCI assessment index. One hundred and thirty-one (4.3%) of the 3072 sick child visits involved no IMCI-related complaints. The mean assessment index for all sick child visits was 4.81 (SD 2.41). Visits involving any IMCI-related complaint were associated with a 1.02 point higher mean assessment index than those without IMCI-related complaints (95% CI, 0.52-1.53; P < 0.001). After adjusting for relevant covariates including patient age, caretaker gender, provider type, provider gender, provider IMCI training status and IMCI guideline availability, we found that children with IMCI-related presenting complaints had a significantly better quality of IMCI screening, than those without IMCI presenting complaints (by 0.75 points; 95% CI, 0.25-1.26; P = 0.003). Our study indicates that children with non-IMCI presenting complaints are at greater risk of suboptimal screening compared to children with IMCI-related presenting complaints. The premise of IMCI is to routinely screen all children for conditions responsible for the major burden of childhood disease in countries like Afghanistan. The study illustrates an important finding that facility and provider capacity needs to be improved, particularly during training, supervision and guideline dissemination to ensure that all children receive routine screening for common IMCI conditions.

204: THE ROLE OF IMCI PROGRAM IN THE RATIONALIZATION OF MEDICAMENT USE IN PEDIATRICS

Background and aims:Integrated management of childhood illness (IMCI) is an EBM guideline prepared by WHO and UNICEF guideline in primary health care for better assessment and management in pediatrics. The...

Profile of C-reactive protein, white cells and neutrophil populations in febrile children from rural north-eastern Tanzania.

IntroductionC-reactive protein (CRP), white blood cell (WBC) and absolute neutrophil counts (ANC) are important inflammatory biomarkers in the early diagnosis of infections. However, little is known on their profile and usefulness in fever case management in children attending outpatient clinic in rural north-eastern Tanzania.MethodsPatients aged between 2 and 59 months presenting with fever at Korogwe District Hospital were enrolled. Venous blood was collected for evaluation of serum CRP, WBC and ANC. Individual patient diagnosis was based on integrated management of childhood illness (IMCI) guidelines and laboratory investigations (blood and urine cultures).ResultsA total of 867 patients were enrolled, out of which 691 (79.7%) had complete clinical and laboratory data available for analysis. Acute upper respiratory tract infection 284 (41.1%), acute gastroenteritis 127 (18.4%) and pneumonia 100 (14.5%) were the most frequent diagnoses. The geometric mean levels of serum CRP, WBC and ANC were 10.4 (95% CI: 9.2 - 11.8), 11.5 (95% CI: 11.1 - 11.9) and 5.5 (95% CI: 5.2 - 5.8), respectively. CRP≤20, WBC≤15 (103cells/µL) and ANC≤10 103cells/µL) were observed in the majority of the patients with upper respiratory tract infection, pneumonia, acute gastroenteritis and non-specific febrile illness. Only serum CRP levels were positively correlated with positive blood cultures at a calculated cut-off value of 37.3 mg/L, giving a specificity of 77.8% and sensitivity of 74.2%.ConclusionCRP assessment together with IMCI guidelines may be useful in assisting the diagnosis and management of paediatric febrile infections in Tanzania.