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Identifying sick children requiring referral to hospital in Bangladesh
H D Kalter1, J A Schillinger, M Hossain
1Department of International Health, Johns Hopkins University, School of Hygiene and Public Health, Baltimore, MD 21205, USA.
Insights
The Integrated Management of Childhood Illness (IMCI) guidelines show good sensitivity in referring young infants and children to hospitals. However, moderate specificity leads to over-referrals, impacting care at primary health facilities.
Area of Science:
- Pediatrics
- Public Health
- Health Systems Strengthening
Background:
- The Integrated Management of Childhood Illness (IMCI) guidelines aim to standardize child healthcare globally.
- Accurate referral of young infants and children to hospitals is crucial for timely and effective treatment.
- Optimizing IMCI guidelines is essential, particularly in low-resource settings with varying disease prevalence.
Purpose of the Study:
- To evaluate and enhance the IMCI guidelines for identifying young infants and children needing hospital referral.
- To assess the sensitivity and specificity of current and modified IMCI guidelines in a low-malaria prevalence area.
- To improve referral accuracy and reduce unnecessary hospital admissions.
Main Methods:
- Prospective sampling of 234 young infants (1 week-2 months) and 668 children (2 months-5 years) in Dhaka, Bangladesh.
- Standardized history taking and physical examinations based on IMCI guidelines by study pediatricians.
- Comparison of IMCI guideline-based referrals with pediatricians' expert judgment on hospital admission necessity.
Main Results:
- The IMCI guidelines demonstrated good sensitivity (84% for infants, 86% for children) for identifying children needing hospital admission.
- Specificity was moderate (54% for infants, 64% for children), indicating a tendency for over-referral.
- Modifying respiratory referral signs improved specificity without compromising sensitivity, particularly for pneumonia cases.
Conclusions:
- The IMCI guidelines are effective in identifying critically ill young infants and children requiring hospital care in low-malaria settings.
- Moderate specificity necessitates adjustments to reduce unnecessary referrals and optimize resource allocation in primary care.
- Further evaluation of IMCI's impact on health outcomes and healthcare systems is needed, considering local treatment practices.
Abstract:
The object of this study was to evaluate and improve the guidelines for the Integrated Management of Childhood Illness (IMCI) with respect to identifying young infants and children requiring referral to hospital in an area of low malaria prevalence. A total of 234 young infants (aged 1 week to 2 months) and 668 children (aged 2 months to 5 years) were prospectively sampled from patients presenting at a children's hospital in Dhaka, Bangladesh. The study paediatricians obtained a standardized history and carried out a physical examination, including items in the IMCI guidelines developed by WHO and UNICEF. The paediatricians made a provisional diagnosis and judged whether each patient needed hospital admission. Using the paediatrician's assessment of a need for admission as the standard, the sensitivity and specificity of the current and modified IMCI guidelines for correctly referring patients to hospital were examined. The IMCI's sensitivity for a paediatrician's assessment in favour of hospital admission was 84% (95% confidence interval (CI): 75-90) for young infants and 86% (95% CI: 81-90) for children, and the specificity was, respectively, 54% (95% CI: 45-63) and 64% (95% CI: 59-69). One fourth or more in each group had a provisional diagnosis of pneumonia, and the IMCI's specificity was increased without lowering sensitivity by modifying the respiratory signs calling for referral. These results show that the IMCI has good sensitivity for correctly referring young infants and children requiring hospital admission in a developing country setting with a low prevalence of malaria. The guidelines' moderate specificity will result in considerable over-referral of patients not needing admission, thereby decreasing opportunities for successful treatment of patients at first-level health facilities. The impact of the IMCI guidelines on children's health and the health care system must be judged in the light of current treatment practices, health outcomes and referral patterns.