In Millennium Development Goal four (MDG4), national
leaders committed to reduce 1990 levels of child mortality in their
countries by two-thirds by 2015. Between 1990 and 2009, child mortality
has reduced globally from 89 to 60 per 1000 live births [1]; however, this
trajectory is not sufficient to achieve MDG4. India has the highest number
of births in the world and also accounts for over 20% of all child deaths.
Achieving MDG4 globally depends on the progress and success in India, more
than in any other single nation [2].
Much progress has been achieved in India, with child
mortality having reduced by more than one third since 1990, to 66 deaths
per 1000 live births in 2009 [1]. However, despite this impressive
improvement, India is unlikely to achieve MDG4 due to persisting high
rates of neonatal mortality. Two-thirds of infant deaths occur in the
neonatal period, and more than one-third of these in the first seven days
of life. Of all babies born annually with low birth weight, 42% (8.3
million) are born in India; increased vulnerability to sepsis and poor
infant feeding practises, mean these newborns are about 20 times more
likely to die in infancy [2]. Furthermore, most babies are born outside of
a health facility, with only 53% having a skilled attendant present at
delivery, so in many cases these babies first contact with health
facilities is when they are sick [1]. Tackling this disproportionate rate
of neonatal mortality is essential for India to achieve MDG4.
Integrated Management of Childhood Illness (IMCI) was
developed by WHO/UNICEF in the mid-1990s, as an integrated approach to
increasing coverage of evidence-based interventions in children aged < 5
years, and is widely implemented in over 100 countries globally. However,
generic IMCI guidelines initially excluded interventions for neonates in
the first seven days of life because there was insufficient evidence
available about clinical predictors of severe illness in this age group
[3].
The Integrated Management of Neonatal and Childhood
Illness (IMNCI) is an important innovation in India. This evidence-based
adaptation of IMCI responds to the particular challenges in India, and, in
particular, aims to reduce neonatal mortality. The IMNCI guidelines in
India include the first seven days of life with the aim of bringing
essential newborn care to the doorstep of households. Frontline health
workers are trained to routinely visit new mothers at home, assist with
breastfeeding and recognise signs of severe illness in newborns. IMNCI
also increases the emphasis on the neonatal period during training [4],
and is now being implemented in almost 300 districts in India [5].
In this edition of Indian Pediatrics, Kaur et
al. [6] present an evaluation of the signs used in the IMNCI algorithm
to identify severe illness in young infants, especially in infants aged
0-7 days. The algorithm primarily aims to correctly identify young infants
requiring referral to a higher level of care. If the algorithm is not
sufficiently sensitive, infants may die at home, having been sent away
from the health facility. However, if the algorithm is not specific, there
will be too many referrals, placing a heavy burden on families and the
health system, and exposing infants to iatrogenic illness. The
investigators showed that, although infants aged 0-7 days presented with
conditions such as birth asphyxia and meconium aspiration, which are
different from those found in older infants, the such infants were
classified them as having possible serious bacterial , and the algorithm
correctly identified them as requiring urgent referral. Although this is
reported as a diagnostic mismatch, appropriate referral rather than
diagnostic accuracy is the aim of the algorithm. Few infants in this age
group were referred unnecessarily, and when this did occur, it was mainly
due to procedural differences between the referral hospital and IMNCI
guidelines in applying the weight cut off for admission.
As much as these results are very encouraging, more
work is needed. The study was conducted at a paediatric referral centre,
so that enrolled infants had already been identified as sick and in need
of care by the parents. The prevalence of severe illness is likely to be
high in this setting, and IMNCI assessments were undertaken by paediatric
staff. More research is required to validate the effectiveness of the
algorithm in the community and primary care setting, where it is intended
to be used, and in particular to evaluate its performance as a screening
tool to identify sick young infants during the routine newborn visits
recommended by IMNCI. Further research is also required to determine the
impact of IMNCI implementation on neonatal mortality.
Competing interests: None stated
Funding: Nil
References
1. UNICEF. The state of the worlds children 2011:
adolescence an age of opportunity. New York: UNICEF; 2011.
2. UNICEF. The state of asia-pacific’s children 2008:
child survival. New York: UNICEF; 2008.
3. The Young Infants Clinical Signs Study Group.
Clinical signs that predict severe illness in children under age 2 months:
a multicentre study. Lancet. 2008;371:135-42.
4. Bahl R. Simple clinical sings to identify severe
neonatal illness. Indian Pediatr. 2007;44:814-6.
5. Nath A. India’s progress toward achieving the
millennium development goals. Indian J Community Med. 2011;36: 85-92.
6. Kaur S, Singh V, Dutta AK, Chandra J. Validation of
IMNCI algorithm for young infants (0-2 months) in India. Indian Pediatr.
2011; 48:955-60.
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