Sick Young Infants Research Articles

A study to assess and compare the level of adherence of IMNCI guidelines among ANMs and ASHA-Sahyoginis in the IMNCI programme implemented in rural areas of Rajasthan

Introduction: The study was undertaken to assess and compare the adherence to IMNCI guidelines among ANMs and ASHA-Sahyoginis in terms of the following five elements of case management process of IMNCI-assessment, classification, treatment, counselling and referrals of sick young infants and children. Methods: Data obtained from 520 IMNCI workers (including 390 ASHA-Sahyoginis and 130 ANMs) working at subcenter / village / anganwadi kendras of the initially and fully IMNCI implemented nine districts of Rajasthan. Multistage (cluster) with stratified proportionate sampling technique was adapted. Direct overt non-participatory observation technique with validated and reliable observation checklists were used to collect data. Results: Findings of the study reveals that 43% and 32% of ANMs showed overall adherence to IMNCI guidelines of young infants and children respectively – whereas only 19% and 3% of ASHA-Sahyoginis showed overall adherence to IMNCI guidelines of young infants and children respectively. Comparative analysis of ANM's and ASHA-Sahyogini's adherence clearly indicated that 43.08% and 31.54% of ANMs showed overall adherence in comparison to 18.72% and 2.56% of ASHA-Sahyogini's overall adherence to IMNCI guidelines for young infants and children respectively. Conclusion: Findings of some previous studies and reports of UNICEF, WHO and Ministry of Health & Family Welfare (MOHFW) Government of India are found to be in line with the current study. The low level of adherence particularly among ASHA-Sahyoginis is because of lack of motivation, monitoring and supervision. Apart from the weak monitoring and supervision, overburden of ANMs with various programmes, maintenance of several types of records and reports serves as a major hindrance in the adherence of ANMs to IMNCI guidelines.

Understanding Bacterial Isolates in Blood Culture and Approaches Used to Define Bacteria as Contaminants: A Literature Review.

Interpretation of blood culture isolates is challenging due to a lack of standard methodologies for identifying contaminants. This problem becomes more complex when the specimens are from sick young infants, as a wide range of bacteria can cause illness among this group. We used 43 key words to find articles published between 1970 and 2011 on blood culture isolates and possible contaminants in the PubMed database. Experts were also consulted to obtain other relevant articles. Selection of articles followed systematic methods considering opinions from more than 1 reviewer. After reviewing the titles of 3869 articles extracted from the database, we found 307 relevant to our objective. Based on the abstracts, 42 articles were selected for the literature review. In addition, we included 7 more articles based on cross-references and expert advice. The most common methods for differentiating blood culture isolates were multiple blood cultures from the same subject, antibiograms and molecular testing. Streptococcus pneumoniae, Hemophilus influenzae, Neisseria meningitidis and group A and B streptococcus were always considered as pathogens, whereas Bacillus sp., Diphtheroids, Propionibacterium and Micrococcus were commonly regarded as contaminants. Coagulase-negative staphylococci were the most frequent isolates and usually reported as contaminants unless the patient had a specific condition, such as long-term hospitalization or use of invasive devices (catheters). Inaccurate interpretation of blood culture may falsely guide treatment and also has long-term policy implications. The combination of clinical and microbiological knowledge, patient's clinical history and laboratory findings are essential for appropriate interpretation of blood culture.

Challenges in Implementation of the ANISA Protocol at the Odisha Site in India.

The Aetiology of Neonatal Infection in South Asia (ANISA) study is being carried out at 5 sites across Bangladesh, India and Pakistan, generating in-depth information on etiologic agents in the community setting. Pregnancies are identified, births are registered and young infants are followed up to 59 days old with regular assessments for possible serious bacterial infection following a generic protocol. Specimens are collected from suspected cases. This article describes the challenges in implementing the generic ANISA protocol and modifications made to accommodate the Odisha site, India. Primary challenges in implementing the protocol are the large geographic area, with a population of over 350,000, to be covered; assessing young infants at home and arranging timely transport of sick young infants to study hospitals for physician confirmation of illness; and specimen collection and treatment. A large workforce is deployed in a 3-tier system in the field, while clinical, microbiology, laboratory and data management teams collaborate dynamically. Mobile phones with text message capability, integration with the Odisha State government's health system, involvement of local communities and strict monitoring at different levels have been critical in addressing these challenges. This article describes the challenges and modalities adopted to collect complex and accurate data on etiology, timing of disease and associated factors for community-acquired neonatal infections. Attention to local culture and customs, training and employing community level workers and supervisors, involving existing government machinery, using technology (cell phones), and uninterrupted systematic monitoring are critical for implementing such complex protocols that aim to collect population-based data to drive policy.

Home visits by community health workers to improve identification of serious illness and care seeking in newborns and young infants from low- and middle-income countries.

The objectives of this review were to evaluate the effect of home visits by trained community health workers (CHWs) to successfully identify newborns and young infants (up to 59 days of age) with serious illness and improve care seeking from a health facility. The authors searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. s of all articles were read by two authors independently and relevant articles selected. Data were extracted in a pretested questionnaire by two authors independently. Statistical analysis was performed using Review Manager software. A meta-analysis of included randomized controlled trials (RCTs) was carried out. Pooled estimates (risk ratios (RRs) with 95% confidence intervals (CIs)) of the evaluated outcome measures were calculated by the generic inverse variance method. Seven articles were identified for inclusion in the review. None of them compared the diagnosis of serious illness in young infants by health workers to a ‘gold standard' diagnosis. Three studies were available for evaluating the ability of CHWs to identify seriously ill young infants/signs of serious illness. These studies suggest that sensitivity to identify serious illness ranged from 33.3 to 90.5% and specificity from 75.61 to 98.4%. For the outcome of improved care seeking from a health facility, after pooling the data from six RCTs with 4760 subjects in the intervention and 4398 subjects in the control arm, there was a significant improvement in care seeking in the home visit arm (RR=1.35; 95% CI=1.15 to 1.58). Moderate quality evidence indicated that home visits by trained CHWs were associated with improved care-seeking for sick young infants from health facilities by appropriate health care providers in resource-limited settings. However, there is a lack of data regarding successful identification of serious illness. Evidence from validation studies supports the implementation of home visits by trained CHWs for improving outcomes in sick newborns and young infants in resource-limited areas. Further well-designed studies evaluating the effect of home visits by CHWs on successful identification of seriously ill newborns and young infants should include verification by a ‘gold standard'.

Community Health Workers Can Identify and Manage Possible Infections in Neonates and Young Infants: MINI - A Model from Nepal

The mortality rates of infants and children aged less than five years are declining globally and in Nepal but less among neonates. Most deliveries occur at home without skilled attendants, and most neonates may not receive appropriate care through the existing medical systems. So, a community-based pilot programme-Morang Innovative Neonatal Intervention (MINI) programme-was implemented in Morang district of Nepal to see the feasibility of bringing the management of sick neonates closer to home. The objective of this model was to answer the question: "Can a team of female community health volunteers and paid facility-based community health workers (collectively called CHWs) within the existing heath system correctly follow a set of guidelines to identify possible severe bacterial infection in neonates and young infants and successfully deliver their treatment?" In the MINI model, the CHWs followed an algorithm to classify sick young infants with possible severe bacterial infection (PSBI). Female Community Health Volunteers (FCHVS) were trained to visit homes soon after delivery, record the birth, counsel mothers on essential newborn care, and assess the newborns for danger-signs. Infants classified as having PSBI, during this or subsequent contacts, were treated with co-trimoxazole and referred to facility-based CHWs for seven-day treatment with injection gentamicin. Additional supervisory support was provided for quality of care and intensified monitoring. Of 11,457 livebirths recorded during May 2005-April 2007, 1,526 (13.3%) episodes of PSBI were identified in young infants. Assessment of signs by the FCHVs matched that of more highly-trained facility-based CHWs in over 90% of episodes. Treatment was initiated in 90% of the PSBI episodes; 93% completed a full course of gentamicin. Case fatality in those who received treatment with gentamicin was 1.5% [95% confidence interval (CI) 1.0-2.3] compared to 5.3% (95% CI 2.6-9.7) in episodes that did not receive any treatment. Within the existing government health infrastructure, the CHWs can assess and identify possible infections in neonates and young infants and deliver appropriate treatment with antibiotics. This will result in improvement in the likelihood of survival and address one of the main causes of neonatal mortality.

Validation of IMNCI algorithm for young infants (0–2 months) in India

To check the validity of Integrated Management of Neonatal and Childhood Illness (IMNCI) algorithm for young infants (0-2 months). Prospective observational study. The outpatient department and emergency room of a medical college attached hospital. 419 infants (176 between 0-7 days, 243 between 7 days to 2 months) underwent a detailed diagnostic assessment and treatment as per the standard protocol of treating unit. These infants also underwent assessment, classification and identification of treatment as per IMNCI algorithm. The diagnostic and therapeutic agreement between standard protocol and IMNCI was computed to assess the validity of IMNCI algorithm. The IMNCI algorithm performed well in identifying sick young infants with sensitivity of 97%, 94% and 95%, and specificity of 85%, 87% and 87% in 0-7 days, 7 days to 2 months and 0-2 months age groups, respectively. The algorithm covered majority (80%) of recorded diagnoses, and could identify bacterial infection with 88.5% sensitivity and 57.4% specificity. Complete diagnostic agreement with gold standard was seen in 50%; overdiagnosis and under diagnosis was seen in 13% and 19%, respectively. Low birthweight and upper respiratory infection were the main reasons for overdiagnosis whereas surgical conditions resulted in under diagnoses in majority. IMNCI algorithm for evaluation and management of young infants has good sensitivity and specificity for referring cases with severe illness.

Why do families of sick newborns accept hospital care? a community-based cohort study in Karachi, Pakistan

ObjectiveSick young infants are at high risk of mortality in developing countries but families often decline hospital referral. Our objective was to identify the predictors of acceptance of referral for hospital care among families of severely ill newborns and infants <59 days old in three low-income communities of Karachi, Pakistan.Study designA cohort of 541 newborns and infants referred from home by community health workers doing household surveillance, and diagnosed with a serious illness at local community clinics between January 1 and December 31, 2007, was followed-up within 1 month of referral to the public hospital.ResultsOnly 24% of families accepted hospital referral. Major reasons for refusal were financial difficulties (67%) and father/elder denying permission (65%). Religious/cultural beliefs were cited by 20% of families. Referral acceptance was higher with recognition of severity of the illness by mother (OR=12.7; 95% CI=4.6–35.2), family’s ability to speak the dominant language at hospital (OR=2.0; 95% CI=1.3–3.1), presence of grunting in the infant (OR=3.3; 95% CI=1.2–9.0), and infant temperature <35.5°C (OR=4.1; 95% CI=2.3–7.4). No gender differential was observed.ConclusionRefusal of hospital referral for sick young infants is very common. Interventions that encourage appropriate care seeking, as well as community-based management of young infant illnesses when referral is not feasible are needed to improve neonatal survival in low-income countries.

Study comparing the management decisions by IMNCI algorithm and pediatricians in a teaching hospital for the young infants between 0 to 2 months

Integrated management of neonatal and childhood illness (IMNCI) was already operational in many states of India, but there were very few studies in Indian scenario comparing its validity and reliability with the decisions of pediatricians. The general objective of the study is to compare the IMNCI decisions with the decisions of pediatricians and the specific objectives are to assess the agreement between IMNCI decisions and the decisions of pediatricians, to assess the under diagnosis and over diagnosis in IMNCI algorithm in comparison to the decisions of pediatricians and to assess the significance of multiple presenting symptoms in IMNCI algorithm. The study was conducted among the sick young infants presenting in pediatric department from January to March 2009. The IMNCI decision was compared with pediatrician's decisions by percent agreement, Kappa and weighted Kappa with the aids of SPSS version 10. The overall diagnostic agreement between IMNCI algorithm and pediatrician's decisions was 55.56%, (Kappa 0.32 and weighted Kappa 0.41) with 33.33% over diagnosis, and 11.11% under diagnosis. 71.88% young infants with multiple symptoms and 40% with single symptom were classified as red by IMNCI algorithm, which is statistically significant (P=0.004) whereas 56.25% young infants with multiple and 31.76% with single symptom were considered admissible by pediatricians, which is not statistically significant (P=0.052).

Clinico-epidemiological profile and predictors of severe illness in young infants (0–59 days) in Ghana

Young infant mortality has remained high and relatively unchanged compared with deaths of older infants. Strategies to reduce infant mortality, however, are mostly targeted at the older child. To describe the clinical profile of sick young infants presenting to a hospital and to define important signs and symptoms that will enable health workers to detect young infants with severe illness requiring hospital admission. Young infants aged 0-59 days presenting to a paediatric out-patient clinic were evaluated by a nurse using a standardised list of signs and symptoms. A paediatrician independently evaluated these children and decided whether they needed hospitalisation. A total of 685 young infants were enrolled, 22% of whom were <7 days of age. The commonest reasons for seeking care were jaundice in the 0-6-day group, skin problems in the 7-27-day group and cough in the 28-59-day group. The primary clinical diagnoses for admissions were sepsis in the 0-6- and 7-27-day groups and pneumonia in the 28-59-day group. Clinical signs and symptoms predicting severe illness requiring admission were general (history of fever, difficult feeding, not feeding well and temperature >37.5 degrees C) and respiratory (respiratory rate > or =60/min, severe chest in-drawing). General and respiratory signs are important predictors for severe illness in young infants. Training peripheral health workers to recognise these signs and to refer to hospital for further assessment and management might have a significant impact on young infant mortality.

Gender Bias in Critically Sick Newborns and Young Infants: An Ethical Dilemma?

Gender Bias in Critically Sick Newborns and Young Infants: An Ethical Dilemma?

The management of sick young infants at primary health centres in a rural developing country

Aims: To investigate the epidemiology of illness among young infants at remote health clinics in a rural developing country, and to determine risk factors for mortality that might be used...

Bacterial Isolates in the Sick Young Infant in Ile-Ife, Nigeria

This prospective study was carried out to determine the bacterial pathogens and their antibiotic sensitivity profile in the sick young infant. All consecutive young infants with features suggestive of infection seen over 5 months at a Comprehensive Health Centre in Ile-Ife, were screened for septicaemia and local bacterial infections. Of the 121 sick young infants screened for infection, 94 (77.7 per cent) had confirmed bacterial infection and 54 (57.4 per cent) of the 94 had confirmed septicaemia. Gram-positive organisms were the commonest bacterial isolates accounting for 204 (81.6 per cent) of the 250 isolates in this study. Staphylococcus aureus was the most frequent organism accounting for 61.2 per cent of all isolates. Gram-negative organisms accounted for 46 (18.4 per cent) of all isolates with Salmonella spp. and Proteus vulgaris predominating. All the bacterial isolates in this study were sensitive to ofloxacin and most were sensitive to the antibiotics commonly employed in the treatment of infections caused by these organisms. However, many of both Grampositive and Gram-negative isolates in this study were resistant to cotrimoxazole. The study highlights the high prevalence of bacterial infections (localized or systemic) among young infants. It also shows that Gram-positive organisms, the principal aetiologic agents, were sensitive to commonly used antibiotics. It is recommended that genticin and cloxacillin or erythromycin should be used as the first-line antibiotics in the treatment of young infants with bacterial infections in Ile-Ife, Nigeria.

Utility of the peripheral blood white blood cell count for identifying sick young infants who need lumbar puncture

Study objective: We assess the utility of the peripheral blood WBC count as a screen for lumbar puncture among young infants evaluated for serious bacterial infections. Methods: We performed logistic regression modeling and receiver operating characteristic curve analysis of peripheral blood WBC count and cerebrospinal fluid WBC count for results obtained from 3- to 89-day-old infants undergoing a full sepsis evaluation. Results: Twenty-two of 5,353 (4.1 per 1,000) infants had acute bacterial meningitis. For diagnosing acute bacterial meningitis, the peripheral blood WBC count was poorly discriminating and significantly inferior to the cerebrospinal fluid WBC count. This was true both when the odds of meningitis were modeled to vary linearly and as a U-shaped function of the peripheral blood WBC count. When relying on single and interval-based high-risk thresholds of peripheral blood WBC counts alone, the majority of infants with acute bacterial meningitis would have been missed. Conclusion: Decisions to perform or withhold lumbar puncture should not be based on prevailing interpretations of the total peripheral blood WBC counts to maximize detection of bacterial meningitis in young infants. [Ann Emerg Med. 2003;41:206-214.]

Careseeking for illness in young infants in an urban slum in India

Illness in infants in the first two months of life can take a precipitous life-threatening course, and requires timely and appropriate medical assessment and management. We conducted a focused ethnographic study of illness in young infants and associated careseeking practices in an urban slum in New Delhi, India, in order to identify the constraints in securing effective care for severe illness in this age group. The findings suggest that maternal recognition of illness is not a limiting factor in the use of health care services for sick young infants in this setting. Mothers respond to a number of important signs of illness, including changes in the young infant's sleeping or feeding behavior, and they are usually prompt in seeking care outside the home. They are not able, however, to discriminate among the many sources of health care available in this setting, and give preference to local unqualified private practitioners. Most practitioners, including qualified medical practitioners, display critical failures in the assessment and management of sick young infants. The continuity and effectiveness of care is further compromised by the caretakers' expectations of rapid cure, which result in discontinued treatment courses and frequent changes in practitioners, and by their reluctance to seek hospital care. The implications of these findings for the design of programs to reduce young infant mortality are discussed. In particular, the feasibility and acceptability of hospital referrals according to current program guidelines are called into question.

Early Routine Lumbar Puncture in Sick Young Infants: Prudent or Unnecessary? • 370

Early Routine Lumbar Puncture in Sick Young Infants: Prudent or Unnecessary? • 370