Academic journal article Bulletin of the World Health Organization

Identifying Sick Children Requiring Referral to Hospital in Bangladesh

Academic journal article Bulletin of the World Health Organization

Identifying Sick Children Requiring Referral to Hospital in Bangladesh

Article excerpt


Since pneumonia and diarrhoea account for the majority of deaths in [is less than] 5-year-old children in developing countries, Ministries of Health have implemented national disease control programmes to improve the diagnosis and treatment of these illnesses. Disease-specific case management guidelines have been developed to aid health auxiliaries working at first-level facilities, a vital component of which is the identification and referral to hospital of severely ill children. Recognizing that diseases, such as pneumonia and malaria may present with similar symptoms, and that many severely ill children have more than one condition needing treatment, WHO and UNICEF recently developed guidelines for the Integrated Management of Childhood Illness (IMCI). These guidelines enable primary health workers to diagnose and manage illnesses which are thought to be responsible for 70% of childhood deaths in developing countries (1).

The IMCI guidelines, which are organized separately for 7-59-day-olds and 2-59-month-olds, use simple clinical signs to classify the illness and its severity. Where the same signs are presented by more than one disease, they are managed by the treatment instructions for the relevant illness classifications. Owing to the nonspecific nature of disease presentation in young infants, most clinical signs of severe illness in this age group are included in a single condition, "possible serious bacterial infection", with other categories covering diarrhoea, malnutrition, and feeding problems. Older infants and children are checked for respiratory and febrile conditions, diarrhoea, ear problems, malnutrition and anaemia with different instructions for febrile illnesses in areas of high and low malaria risk. The immunization status of all patients is checked, needed immunizations are given, and treatments and instructions are provided to the caregiver.

The IMCI algorithm is designed for use in first level outpatient health facilities which have limited diagnostic and treatment capabilities, and health auxiliary staff with limited training. Many developing countries now have a policy on essential drugs for primary care (2), and better-stocked health facilities will carry the nationally approved one oral antibiotic for pneumonia and one for dysentery, a parenteral antibiotic for severe disease, an antimalarial (in malarious areas), paracetamol, oral rehydration packets, vitamin A, and iron. Some may also carry an antibiotic eye ointment and gentian violet for oral lesions. These are the treatments prescribed by the IMCI algorithm, together with instructions to the mothers for home care.

Hospitals and other inpatient facilities are staffed by physicians, often have more advanced diagnostic (including X-ray and laboratory) facilities, and usually have a greater range of drugs. However, the nearest hospital may be far from a first-level facility, transportation may be limited, and care is more expensive. The IMCI guidelines are designed to be highly sensitive on the referral of patients with a possible severe illness, and ideally they would exclude those whose illness does not require care at a hospital. Previous studies have examined the validity of clinical signs of respiratory illness severity (3-6) and identified signs of severe illness due to other conditions (7-9), which are included in the IMCI guidelines. Because of the need to assess the updated algorithm's performance using these signs, particularly with young infants, we compared the IMCI recommendation for referral with the judgement of an expert clinician on the need for hospitalization.

Patients and methods

We carried out a prospective study of [is less than] 5-year-old children presenting for medical care at the outpatient or emergency department of the Dhaka Shishu (Children's) Hospital in Dhaka, Bangladesh. Because we sought to validate the content of the IMCI referral guidelines, rather than the ability of health auxiliaries to use the instructions, all clinical data were collected by the study physicians. …

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