Integrated Management Of Childhood Illness Research Articles

Assessment of factors related to caregivers and children on the IMCI program outcomes in Baghdad City in 2021

Background: The implementation of the Integrated Management of Childhood Illness (IMCI) program has led to enhancement in outcomes for many treatable childhood diseases. This study aims to assess how implementing IMCI affects child mortality and morbidity in Iraq. Methods: A cross-sectional study spanning from January to December 2021 was carried out at primary healthcare centers (PHCCs) with IMCI units in Baghdad, Iraq. Using a lottery sampling method, 40 PHCCs were randomly chosen from a total of 235 centers across both sides of the city. A universal sampling technique was adopted to select all children attending these PHCCs regularly. With a p-value below 5%, multiple logistic regression analyses were performed to identify the significant independent predictors at a 95% confidence interval. Results: The majority of caregivers were mothers (97.8%), aged 20 to 30 years (75.8%), and housewives (59.2%). Sixty percent of children (6 to 35 months) had normal anthropometric measurements. Bottle feeding was common (44.2%), and most children had a normal neonatal history (82.9%). In bivariate analysis, the severity of illness, severe cases of diarrhea, and acute respiratory infection (ARI) showed significant associations with worsened or not improved outcomes (χ2 = 18.900, p < 0.001; χ2 = 6.265, p= 0.016; and χ2 = 7.549, p= 0.003, respectively). However, multiple logistic regression analysis indicated that mild and moderate illness severity (OR = 10.634, 95% CI: 6.985 to 16.192, p < 0.001), strict breastfeeding (OR = 3.307, 95% CI: 1.703 to 6.421, p < 0.001), and completing treatment at home (OR = 6.190, 95% CI: 4.115 to 9.311, p < 0.001) significantly improved outcomes through IMCI services. Conclusion: Severe illness, especially in diarrhea and ARI, correlates with poorer outcomes. Conversely, exclusive breastfeeding, prompt medical attention within a day of illness onset, and completing home treatment are associated with improved outcomes.

Impact to Integrated Management of Childhood Illness (IMCI) Implementation in Developing Countries: A Literature Review

Impact to Integrated Management of Childhood Illness (IMCI) Implementation in Developing Countries: A Literature Review

FACTORS INFLUENCING INTEGRATED MANAGEMENT OF NEWBORN CHILDHOOD ILLNESSES (IMNCI) UPTAKE AMONG CHILDREN IN CMH GILGIT, PAKISTAN

In developing countries, about 9 million children die before reaching the age of 5 every year, with 70% of these deaths attributable to five central diseases (measles, diarrhea, pneumonia, malaria, and malnutrition). The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) have recognized the importance of early care-seeking and have developed the "integrated management of childhood illness" to promote proper healthcare practices within families and communities and decrease the mortality rate of children under five in developing countries. This study aimed to improve the health-seeking behaviour of mothers and reduce the burden of disease in children under five, with specific objectives to assess the factors affecting the uptake of integrated management of childhood illness (IMNCI) and the health-seeking behaviour of mothers. Using a structured questionnaire, a hospital-based cross-sectional study was conducted on 156 randomly selected parents of patients at CMH, Gilgit, from August to December 2016. The chi-square test determined associations between different factors and mothers' health-seeking behaviour. The results showed strong associations at p=0.05 and a 95% confidence interval with n=156. Strong associations were found between the first care given and the head of the family (p=0.02) and between health problems and the head of the family (p=0.01). The findings also indicated a strong relationship between the head of the family and restrictions when seeking care for a sick child (p=0.00). Maternal education positively impacts health outcomes, leading to fewer family restrictions, early identification of problems, and improved decision-making when seeking healthcare.

Perspectives of healthcare workers on integrated management of childhood illness in Pakistan: A phenomenological approach.

In 2019, an estimated 5.2 million deaths were reported among children less than 5years of age. At primary healthcare level, healthcare workers (HCWs) mostly rely on history and clinical findings and less on inadequate diagnostic facilities. To enhance case management skills of HCWs, World Health Organization devised an integrated management of childhood illnesses (IMCI) strategy in 1995, modified to distance learning IMCI in 2014. A qualitative phenomenological study was conducted to explore perceptions of HCWs about standard and distance IMCI. Four focus group discussions were conducted with purposively selected 26 HCWs (IMCI trained) from 26 basic health units of Abbottabad district in Pakistan. Gadamer's philosophical hermeneutics were adopted during the inductive thematic analysis. Five themes that emerged are inexorable health seeking behaviors, IMCI being a comprehensive algorithm for consultation, a tedious protocol, scaling up protocol to specialists and private practitioners, and administrative insufficiency by the department of health. Improvement in case management skills of HCWs was reported as a result of IMCI trainings. It needs administrative support, regulations to control poly-pharmacy and provision of drugs without prescription, and a curb on political and bureaucratic interference.

Integrated management of childhood illness in Rwanda: Impact of mentorship on the quality of care in Nyanza and Huye districts

AbstractBackgroundIn Rwanda, health posts (HPs) are intermediary primary care facilities that provide comprehensive primary care services to communities and are located at a reasonable walking distance from people's homes. We assessed the readiness of HPs for Integrated Management of Childhood Illness (IMCI) services and examined changes in the quality of care for IMCI services between districts that implemented IMCI mentorship program (Nyanza district) and Huye district which it did not.MethodsWe conducted a prospective cohort study to assess whether there was change in the quality of IMCI care provided at 17 Nyanza HPs 1‐year after IMCI mentorship implementation. The readiness of HPs for IMCI was assessed across nine factors, resulting in essential (all factors) and desirable (less than seven factors) composite scores. Unpaired t‐tests were used to measure changes in IMCI quality.ResultsThe HPs with IMCI mentorship had an increase in mean desirable (0.7–0.89) and essential (0.61–0.78) composite scores compared to non‐mentored HPs in Huye. The nurses who received mentorship program had improved scores in factors like IMCI training, service package availability, register availability, supportive supervision, and basic equipment availability. Quality improvements in IMCI assessments were observed in vital sign registration, danger sign detection, cough identification, malnutrition screening, and tuberculosis sign identification in the mentored HPs.ConclusionMentorship of nurses in HPs holds promise for enhancing facility readiness and IMCI service quality. Before expanding clinical mentorship, identified gaps such as staffing, supply chains, and health financing need to be addressed.

Integrated Management of Childhood Illness implementation in Nepal: understanding strategies, context, and outcomes

BackgroundHealth system-delivered evidence-based interventions (EBIs) are important to reducing amenable under-5 mortality (U5M). Implementation research (IR) can reduce knowledge gaps and decrease lags between new knowledge and its implementation in real world settings. IR can also help understand contextual factors and strategies useful to adapting EBIs and their implementation to local settings. Nepal has been a leader in dropping U5M including through adopting EBIs such as integrated management of childhood illness (IMCI). We use IR to identify strategies used in Nepal’s adaptation and implementation of IMCI.MethodsWe conducted a mixed methods case study using an implementation research framework developed to understand how Nepal outperformed its peers between 2000–2015 in implementing health system-delivered EBIs known to reduce amenable U5M. We combined review of existing literature and data supplemented by 21 key informant interviews with policymakers and implementers, to understand implementation strategies and contextual factors that affected implementation outcomes. We extracted relevant results from the case study and used explanatory mixed methods to understand how and why Nepal had successes and challenges in adapting and implementing one EBI, IMCI.ResultsStrategies chosen and adapted to meet Nepal’s specific context included leveraging local research to inform national decision-makers, pilot testing, partner engagement, and building on and integrating with the existing community health system. These cross-cutting strategies benefited from facilitating factors included community health system and structure, culture of data use, and local research capacity. Geography was a critical barrier and while substantial drops in U5M were seen in both the highest and lowest wealth quintiles, with the wealth equity gap decreasing from 73 to 39 per 1,000 live births from 2001 to 2016, substantial geographic inequities remained.ConclusionsNepal’s story shows that implementation strategies that are available across contexts were key to adopting and adapting IMCI and achieving outcomes including acceptability, effectiveness, and reach. The value of choosing strategies that leverage facilitating factors such as investments in community-based and facility-based approaches as well as addressing barriers such as geography are useful lessons for countries working to accelerate adaptation and implementation of strategies to implement EBIs to continue achieving child health targets.

Examining the implementation of facility-based integrated management of childhood illness and insecticide treated nets in Bangladesh: lessons learned through implementation research

BackgroundBangladesh significantly reduced under-5 mortality (U5M) between 2000 and 2015, despite its low economic development and projected high mortality rates in children aged under 5 years. A portion of this success was due to implementation of health systems-delivered evidence-based interventions (EBIs) known to reduce U5M. This study aims to understand how Bangladesh was able to achieve this success between 2000 and 2015. Implementation science studies such as this one provide insights on the implementation process that are not sufficiently documented in existing literature.MethodsBetween 2017 and 2020, we conducted mixed methods implementation research case studies to examine how six countries including Bangladesh outperformed their regional and economic peers in reducing U5M. Using existing data and reports supplemented by key informant interviews, we studied key implementation strategies and associated implementation outcomes for selected EBIs and contextual factors which facilitated or hindered this work. We used facility-based integrated management of childhood illnesses and insecticide treated nets as examples of two EBIs that were implemented successfully and with wide reach across the country to understand the strategies put in place as well as the facilitating and challenging contextual factors.ResultsStrategies which contributed to the successful implementation and wide coverage of the selected EBIs included community engagement, data use, and small-scale testing, important to achieving implementation outcomes such as effectiveness, reach and fidelity, although gaps persisted including in quality of care. Key contextual factors including a strong community-based health system, accountable leadership, and female empowerment facilitated implementation of these EBIs. Challenges included human resources for health, dependence on donor funding and poor service quality in the private sector.ConclusionAs countries work to reduce U5M, they should build strong community health systems, follow global guidance, adapt their implementation using local evidence as well as build sustainability into their programs. Strategies need to leverage facilitating contextual factors while addressing challenging ones.

Electronic Integrated Management of Childhood Illness (eIMCI): a randomized controlled trial to evaluate an electronic clinical decision-making support system for management of sick children in primary health care facilities in South Africa

BackgroundElectronic clinical decision-making support systems (eCDSS) aim to assist clinicians making complex patient management decisions and improve adherence to evidence-based guidelines. Integrated management of Childhood Illness (IMCI) provides guidelines for management of sick children attending primary health care clinics and is widely implemented globally. An electronic version of IMCI (eIMCI) was developed in South Africa.MethodsWe conducted a cluster randomized controlled trial comparing management of sick children with eIMCI to the management when using paper-based IMCI (pIMCI) in one district in KwaZulu-Natal. From 31 clinics in the district, 15 were randomly assigned to intervention (eIMCI) or control (pIMCI) groups. Computers were deployed in eIMCI clinics, and one IMCI trained nurse was randomly selected to participate from each clinic. eIMCI participants received a one-day computer training, and all participants received a similar three-day IMCI update and two mentoring visits. A quantitative survey was conducted among mothers and sick children attending participating clinics to assess the quality of care provided by IMCI practitioners. Sick child assessments by participants in eIMCI and pIMCI groups were compared to assessment by an IMCI expert.ResultsSelf-reported computer skills were poor among all nurse participants. IMCI knowledge was similar in both groups. Among 291 enrolled children: 152 were in the eIMCI group; 139 in the pIMCI group. The mean number of enrolled children was 9.7 per clinic (range 7-12). IMCI implementation was sub-optimal in both eIMCI and pIMCI groups. eIMCI consultations took longer than pIMCI consultations (median duration 28 minutes vs 25 minutes; p = 0.02). eIMCI participants were less likely than pIMCI participants to correctly classify children for presenting symptoms, but were more likely to correctly classify for screening conditions, particularly malnutrition. eIMCI participants were less likely to provide all required medications (124/152; 81.6% vs 126/139; 91.6%, p= 0.026), and more likely to prescribe unnecessary medication (48/152; 31.6% vs 20/139; 14.4%, p = 0.004) compared to pIMCI participants.ConclusionsImplementation of eIMCI failed to improve management of sick children, with poor IMCI implementation in both groups. Further research is needed to understand barriers to comprehensive implementation of both pIMCI and eIMCI. (349)Clinical trials registrationClinicaltrials.gov ID: BFC157/19, August 2019.

The Diagnostic Association of Radiological and Clinicopathological Parameters in Community-Acquired Pneumonia in Children: A Cross-Sectional Study.

Background Globally, pneumonia is one of the significant causes of death in children under the age of five years. Assessment of disease severity is essential for clinical decision-making. Clinicians in resource-limited settings use the WHO Integrated Management of Childhood Illness (IMNCI) guidelines to diagnose and treat pneumonia. Chest X-rays and blood biomarkers are frequently performed in children presenting with pneumonia, but their role in clinical decision-making is limited. Objective To evaluate the association of chest X-ray results, clinical parameters, and blood inflammatory biomarkers with the severity of community-acquired pneumonia (CAP) in children to decide which tests are helpful in accurately classifying the severity of pneumonia. Methods This cross-sectional, analytical study was conducted at the Combined Military Hospital, Lahore, among 421 children aged two months to five years who were admitted with complaints of cough and difficulty breathing and were COVID-19 negative. Data was collected through a structured questionnaire, including demographic information and clinical categorization of pneumonia severity using WHO criteria, SpO2 levels, chest X-rays, complete blood count (CBC), and C-reactive protein (CRP)levels obtained within 24 hours of admission. Statistical evaluation of 323 children was done using SPSS version 26, and analysis of variance (ANOVA), chi-square test, and Fisher's exact test were applied to determine statistical significance. p-Value <0.05 was considered significant. Results The median age of the study population was eight months (IQR: 3-20 months); 113 (33.1%) were girlsand 127 (37.2%) were underweight children. Eighteen (5.3%) patients had no pneumonia, 245 (71.8%) patients had non-severe pneumonia, and 78 (22.9%) patients had severe pneumonia. The clinical features of severe pneumonia were more common in children with radiologic findings of alveolarCAPthan non-alveolar CAP (36.2% and 20%, respectively, p: 0.05). A higher percentage of patients with alveolar CAP had CRP >6 mg/dL than non-alveolar CAP (69.9% and 35%, respectively, p < 0.001). Patients with undernutrition (WAZ <-2 SD), hypoxemia (SpO2<95%), and having CRP >6 mg/dL were associated with clinical features of severe pneumonia (46.1% vs. 33.8%, 100% vs 47.3%, and 67.9% vs 48.5%, respectively, p < 0.05). A significantly greater frequency of a bilateral multifocal distribution (p = 0.020), and the involvement of the right paracardiac region (p = 0.043) and the left lower lobe (p = 0.007) in those with severe pneumonia was observed. Conclusion Clinical diagnosis of pneumonia, along with the assessment of risk factors, including undernutrition and hypoxemia, should be adequate to diagnose pneumonia in children. Chest X-rays and CRP levels can be helpful in hospitalized children for whom physicians have difficulty deciding about antibiotic prescriptions, but their role in routinely classifying the severity of pneumonia in children is limited.

Development and evaluation of a clinical guideline for a paediatric telemedicine service in a low-resource setting

ObjectiveTo develop and evaluate a guideline for a paediatric telemedicine and medication delivery service (TMDS).MethodsA clinical guideline for paediatric telemedicine was derived from the World Health (WHO) Organization Integrated Management...

Integrated Management of Childhood Illness in Oman: 16 Years of Pre-service Initiatives for Education and Training.

Each year, approximately 10 million children worldwide die before reaching the age of five, yet two-thirds of these deaths could be prevented with effective, low-cost interventions. The Integrated Management of Childhood Illness (IMCI) strategy was adopted in 1996 by the World Health Organization and the United Nations Children's Fund to address the holistic well-being of children. The ultimate goals of IMCI are to develop a healthcare system that adheres to best practices and to improve the knowledge, attitudes, and skills of healthcare professionals. This paper describes the IMCI in pre-service education and training and the steps involved in integrating it into the nursing course on child health at Oman College of Health Sciences. The program aims to reduce the morbidity and mortality rate of children under five years of age, as well as the severity of their diseases. The Oman College of Health Sciences was the first healthcare academic institution in Oman to implement IMCI in nursing education to strengthen the nursing students' knowledge, skills, and clinical practice.

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.

The diagnosis and management of dehydration in children with wasting or nutritional edema: A systematic review.

Dehydration is a major cause of death among children with wasting and diarrhea. We reviewed the evidence for the identification and management of dehydration among these children. Two systematic reviews were conducted to assess 1) the diagnostic performance of clinical signs or algorithms intended to measure dehydration, and 2) the efficacy and safety of low-osmolarity ORS versus ReSoMal on mortality, treatment failure, time to full rehydration, and electrolyte disturbances (management review). We searched PubMed/Medline, Embase, and Global Index Medicus for studies enrolling children 0-60 months old with wasting and diarrhea. The diagnostic review included four studies. Two studies found the Integrated Management of Childhood Illness (IMCI) and the Dehydration: Assessing Kids Accurately (DHAKA) algorithms had similar diagnostic performance, but both algorithms had high false positive rates for moderate (41% and 35%, respectively) and severe (76% and 82%, respectively) dehydration. One further IMCI algorithm study found a 23% false positive rate for moderate dehydration. The management review included six trials. One trial directly compared low osmolarity ORS to ReSoMal and found no difference in treatment failure rates, although ReSoMal had a shorter duration of treatment (16.1 vs. 19.6 hours, p = 0.036) and a higher incidence of hyponatremia. Both fluids failed to correct a substantial number of hypokalemia cases across studies. In conclusion, the IMCI dehydration assessment has comparable performance to other algorithms among wasted children. Low osmolarity ORS may be an alternative to ReSoMal for children with severe wasting, but might require additional potassium to combat hypokalemia.

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.

The Implementation of Integrated Management of Childhood Illness (IMCI) in Sick Children from 2 Months up to 5 Years Age Old with Diarrhea in Community Health Center

Integrated Management of Childhood Illnesses (IMCI) is a program that focuses on the main childhood diseases that occur in children under five years of age with a focus on pneumonia (acute respiratory infection), diarrhea, malaria, measles, dengue hemorrhagic fever (DHF), ear and malnutrition. Diarrhea is a global health problem that causes high morbidity and mortality in developing countries due to poor environmental sanitation and hygiene, inadequate water supply, poverty and limited access to education. IMCI is a strategy that focuses on child as a whole, not on a single disease or condition, but on a combination of illnesses that need to be treated in an integrated manner at home and in primary health care facilities. Based on the Becora Community Health Center report that cases handled using the IMCI strategy totaled 2,204 cases in 2021, 4,273 cases in 2022 and 3,160 cases, from January to June 2023. Diarrhea cases ranked first, namely 584 cases in 2021, and in 2022 experienced an increase to 758 cases and until June 2023 cases of diarrhea reached 416 cases. The purpose of this residency is to know the management of cases of diarrhea by using IMCI strategies at the Becora Health Center, Dili, Timor Leste. Using descriptive studies because they only wanted to know the frequency distribution of cases handled with IMCI and specifically wanted to observe the management procedures in cases with diarrhea. Based on the results residence from 17-29 July 2023, 598 cases were not handled according to the IMCI strategy, of which 10.37% (n=62) cases had diarrhea and 0.5% (n=3) dysentery cases. In accordance with the results of observations that the IMCI management procedures are not in accordance with ministry standards or policies issued by the Ministry of Health Timor Leste. During residence it appears that health professionals conducting consultations are more directed to using general consultations than using the IMCI strategy.

Transitions from hospital to home: A mixed methods study to evaluate pediatric discharges in Uganda.

The World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) guidelines recognize the importance of discharge planning to ensure continuation of care at home and appropriate follow-up. However, insufficient attention has been paid to post discharge planning in many hospitals contributing to poor implementation. To understand the reasons for suboptimal discharge, we evaluated the pediatric discharge process from hospital admission through the transition to care within the community in Ugandan hospitals. This mixed methods prospective study enrolled 92 study participants in three phases: patient journey mapping for 32 admitted children under-5 years of age with suspected or proven infection, discharge process mapping with 24 pediatric healthcare workers, and focus group discussions with 36 primary caregivers and fathers of discharged children. Data were descriptively and thematically analyzed. We found that the typical discharge process is often not centered around the needs of the child and family. Discharge planning often does not begin until immediately prior to discharge and generally does not include caregiver input. Discharge education and counselling are generally limited, rarely involves the father, and does not focus significantly on post-discharge care or follow-up. Delays in the discharge process itself occur at multiple points, including while awaiting a physical discharge order and then following a discharge order, mainly with billing or transportation issues. Poor peri-discharge care is a significant barrier to optimizing health outcomes among children in Uganda. Process improvements including initiation of early discharge planning, improved communication between healthcare workers and caregivers, as well as an increased focus on post-discharge care, are key to ensuring safe transitions from facility-based care to home-based care among children recovering from severe illness.

Digitalizing Clinical Guidelines: Experiences in the Development of Clinical Decision Support Algorithms for Management of Childhood Illness in Resource-Constrained Settings.

Clinical decision support systems (CDSSs) can strengthen the quality of integrated management of childhood illness (IMCI) in resource-constrained settings. Several IMCI-related CDSSs have been developed and implemented in recent years. Yet, despite having a shared starting point, the IMCI-related CDSSs are markedly varied due to the need for interpretation when translating narrative guidelines into decision logic combined with considerations of context and design choices. Between October 2019 and April 2021, we conducted a comparative analysis of 4 IMCI-related CDSSs. The extent of adaptations to IMCI varied, but common themes emerged. Scope was extended to cover a broader range of conditions. Content was added or modified to enhance precision, align with new evidence, and support rational resource use. Structure was modified to increase efficiency, improve usability, and prioritize care for severely ill children. The multistakeholder development processes involved syntheses of recommendations from existing guidelines and literature; creation and validation of clinical algorithms; and iterative development, implementation, and evaluation. The common themes surrounding adaptations of IMCI guidance highlight the complexities of digitalizing evidence-based recommendations and reinforce the rationale for leveraging standards for CDSS development, such as the World Health Organization's SMART Guidelines. Implementation through multistakeholder dialogue is critical to ensure CDSSs can effectively and equitably improve quality of care for children in resource-constrained settings.

Neuroblastoma: Can lessons from the past help to improve the future?

Background. The outcome of patients with neuroblastoma in South Africa has always been very poor. We conducted a retrospective study in one state-funded paediatric oncology unit (POU), to describe the clinical course, evaluate prognostic factors and report outcomes of patients with neuroblastoma.Methods. We analysed routine data from one POU, gathered between 1993 and 2018. Kaplan-Meier curves were used to illustrate 2-year survival rates and to evaluate possible prognostic factors.Results. Data from 87 patients were included and analysed. The median age was 41 months. The majority of the patients presented with stage 4 disease (77%). The most common presenting symptoms were bone pain, loss of weight, and abdominal distention. Chemotherapy was administered to 74 patients, and only 5 patients (6%) received palliative chemotherapy as first-line treatment. Only 18 of the 87 patients had surgery (21%) and 13 of 87 had radiation (15%), while 10 patients received palliative radioactive iodine (131I-miBG) therapy. Patients with ferritin levels &gt;120 ng/dL did not have a poorer outcome, and those with a raised lactate dehydrogenase (LDH) level displayed a shorter survival time but it was not statistically significant. The 2-year overall survival was 24% for the whole cohort and 16% for the stage 4 patients at diagnosis.Conclusion. Neuroblastoma is a disease with a dismal outcome in our POU, mostly as a result of late presentation. To improve prognosis the focus should be on recognising danger signs to ensure early diagnosis and referral. We recommend adding danger signs for childhood cancer to the Integrated Management of Childhood Illness (IMCI) strategy in an attempt to improve early recognition and diagnosis of childhood cancer.

The 2022 Indonesia Integrated Management of Childhood Illness (IMCI): Advantages of the Chart Booklet updates during the COVID-19 pandemic.

The 2022 Indonesia Integrated Management of Childhood Illness (IMCI): Advantages of the Chart Booklet updates during the COVID-19 pandemic.

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.