Search

OBJECTIVE: The multi-country evaluation of Integrated Management of Childhood Illness (IMCI) effectiveness, cost and impact (MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. MCE studies are under way in Bangladesh, Brazil, Peru, Uganda and the United Republic of Tanzania. The objective of this analysis from the Bangladesh MCE study was to describe the quality of care delivered to sick children under 5 years old in first-level government health facilities, to inform government planning of child health programmes. METHODS: Generic MCE Health Facility Survey tools were adapted, translated and pre-tested. Medical doctors trained in IMCI and these tools conducted the survey in all 19 health facilities in the study areas. The data were collected using observations, exit interviews, inventories and interviews with facility providers. FINDINGS: Few of the sick children seeking care at these facilities were fully assessed or correctly treated, and almost none of their caregivers were advised on how to continue the care of the child at home. Over one-third of the sick children whose care was observed were managed by lower-level workers who were significantly more likely than higher-level workers to classify the sick child correctly and to provide correct information on home care to the caregiver. CONCLUSION: These results demonstrate an urgent need for interventions to improve the quality of care provided for sick children in first-level facilities in Bangladesh, and suggest that including lower-level workers as targets for IMCI case-management training may be beneficial. The findings suggest that the IMCI strategy offers a promising set of interventions to address the child health service problems in Bangladesh.

OBJECTIVE: To determine whether the fever module in the WHO/UNICEF guidelines for the integrated management of childhood illness (IMCI) identifies children with bacterial infections in an area of low malaria prevalence. METHODS: Physicians assessed a systematic sample of 669 sick children aged 2-59 months who presented to the outpatient department of Dhaka Shishu Hospital, Bangladesh. FINDINGS: Had IMCI guidelines been used to evaluate the children, 78% of those with bacterial infections would have received antibiotics: the majority of children with meningitis (100%), pneumonia (95%), otitis media (95%) and urinary tract infection (83%); and 50% or less of children with bacteraemia (50%), dysentery (48%), and skin infections (30%). The current fever module identified only one additional case of meningitis. Children with bacteraemia were more likely to be febrile, feel hot, and have a history of fever than those with dysentery and skin infections. Fever combined with parental perception of fast breathing provided a more sensitive fever module for the detection of bacteraemia than the current IMCI module. CONCLUSIONS: In an area of low malaria prevalence, the IMCI guidelines provide antibiotics to the majority of children with bacterial infections, but improvements in the fever module are possible.

Background/Objectives: Many children have diets deficient in both iron and zinc, but there has been some evidence of negative interactions when they are supplemented together. The optimal delivery approach would maximize clinical benefits of both nutrients. We studied the effectiveness of different iron and zinc supplement delivery approaches to improve diarrhea and anemia in a rural Bangladesh population. Study Design: Randomized, double blind, placebo-controlled factorial community trial. Results: Iron supplementation alone increased diarrhea, but adding zinc, separately or together, attenuated these harmful effects. Combined zinc and iron was as effective as iron alone for iron outcomes. All supplements were vomited Conclusions: Separate and combined administration of iron and zinc are equally effective for reducing diarrhea, hospitalizations and improving iron outcomes. There may be some benefit in separate administration in stunted children. European journal of Clinical Nutrition (2010) 64, 153-160; doi:10.1038/ejcn.2009.127.; published online 11 November 2009 Keywords: iron; zinc; supplement; delivery; interaction; diarrhea, Introduction Zinc and iron deficiencies often co-exist in developing nations. These minerals are derived from similar food sources and absorption can be inhibited by phytate-containing cereals (Gibson, 1994). Concomitant malnutrition, [...]

Background/Objectives: Zinc is an essential micronutrient and deficiency can lead to an increased risk for infectious diseases and growth retardation among children under 5 years of age. We aimed to estimate disease-specific and all-cause mortality attributable to zinc deficiency. Subject/Methods: We estimated the prevalence of zinc deficiency in Latin America, Africa and Asia, where based on zinc availability in the diet and childhood stunting rates, zinc deficiency is widespread. The relative risks of death among zinc-deficient children for diarrhea, malaria and pneumonia were estimated from randomized controlled trials. We used the comparative risk assessment methods to calculate deaths and burden of disease (measured in disability-adjusted life years, DALYs) from each of these three diseases attributable to zinc deficiency in these regions. Results: Zinc deficiency was responsible for 453 207 deaths (4.4% of childhood deaths), and 1.2% of the burden of disease (3.8% among children between 6 months and 5 years) in these three regions in 2004. Of these deaths, 260 502 were in Africa, 182 546 in Asia and 10 159 in Latin America. Zinc deficiency accounted for 14.4% of diarrhea deaths, 10.4% of malaria deaths and 6.7% of pneumonia deaths among children between 6 months and 5 years of age. Conclusions: Zinc deficiency contributes to substantial morbidity and mortality, especially from diarrhea. Zinc supplementation provided as an adjunct treatment for diarrhea may be the best way to target children most at risk of deficiency. doi:10.1038/ejcn.2008.9; published online 13 February 2008 Keywords: zinc; burden of disease; diarrhea; pneumonia; malaria, Introduction Zinc is an essential micronutrient for human health, growth and development (WHO, 1996). Human zinc deficiency was first recognized in the 1960s among adolescent boys in Iran and Egypt [...]

Objectives: To determine the effect of low-dose weekly supplementation with iron, zinc or both on growth of infants from 6 to 12 months of age. Subjects/Methods: A total of 645 breastfed infants age 6 months who were not severely anemic (Hb [greater than or equal to] 90g [l.sup.-1]) or severely malnourished (weight-for-age [greater than or equal to] 60% median) were randomized to receive 20 mg iron and 1 mg riboflavin; 20 mg zinc and 1 mg riboflavin; 20 mg iron, 20 mg zinc and 1 mg riboflavin; or riboflavin alone (control) weekly for 6 months. Results: Baseline characteristics were similar among the four supplementation groups. Weight, length and mid-upper arm circumference were assessed at baseline, 8, 10 and 12 months of age. There was no interaction of iron and zinc when given in a combined supplement on either weight or length (P> 0.05). There were no effects of either iron or zinc on the rate of length or weight gain for all infants or when stratified by baseline Hb concentration. Conclusions: Weekly supplementation of 20 mg Fe, 20 mg Zn, or both does not benefit growth among infants 6-12 months of age in rural Bangladesh, a region with high rates of anemia and zinc deficiency. doi:10.1038/sj.ejcn.1602905; published online 19 September 2007 Keywords: supplementation; iron; zinc; growth, Introduction Micronutrient malnutrition is a widespread problem in low-income populations and deficiency in one or more nutrients may be a growth-limiting factor for young children in developing countries (Allen, 1994). [...]

Objective To assess the rates, timing and causes of neonatal deaths and the burden of stillbirths in rural Uttar Pradesh, India. We discuss the implications of our findings for neonatal interventions. Methods We used verbal autopsy interviews to investigate 1048 neonatal deaths and stillbirths. Findings There were 430 stillbirths reported, comprising 41% of all deaths in the sample. Of the 618 live births, 32% deaths were on the day of birth, 50% occurred during the first 3 days of life and 71% were during the first week. The primary causes of death on the first day of life (i.e. day 0) were birth asphyxia or injury (31%) and preterm birth (26%). During aays 1-6, the most frequent causes of death were preterm birth (30%) and sepsis or pneumonia (25%). Half of all deaths caused by sepsis or pneumonia occurred during the first week of life. The proportion of deaths attributed to sepsis or pneumonia increased to 45% and 36% during days 7-13 and 14-27, respectively. Conclusion Stillbirths and deaths on the clay of birth represent a large proportion of perinatal and neonatal deaths, highlighting an urgent need to improve coverage with skilled birth attendants and to ensure access to emergency obstetric care. Health interventions to improve essential neonatalcare and care-seeking behavior are also needed, particularly for preterm neonates in the early postnatal period. Objectivo Evaluar las taux, la repartition dans le temps et les causes des deces neonataux et de la charge de mortinatalite dans une population rurale de l'Uttar Pradesh, en Inde. Les implications des resultats de l'etude pour les interventions en sante neonatale sont ensuite examinees. Methodes On a analyse 1048 cas d'enfants mort-nes ou decedes pendant la periode neonatale a partir des interrogatoires realises dans le cadre des autopsies verbales. Resultats Le nombre de cas d'enfants mort-nes notifies s'elevait a 430, soit 41% de l'ensemble des deces dans l'echantillon. Sur les 618 enfants nes vivants, 32 % sont morts le jour de la naissance, 50 % au cours des 3 premiers jours de vie et 71% pendant la premiere semaine. Les principales causes de deces au premier jour de vie (appele jour 0) etaient l'asphyxie ou les traumatismes a la naissance (31%) et la naissance avant terme (26 %). Pendant les jours 1 a 6, les causes de deces les plus frequentes etaient la naissance avant terme (30 %) et la presence d'une infection grave ou d'une pneumonie (25 %). La moitie des deces par infection grave ou par pneumonie se produisaient pendant la premiere semaine de vie. La proportion de deces attribuables a une infection grave ou a une pneumonie passait a 45 % et a 36 % pour les periodes allant du 7e au 13e jours et du 14e au 27e jours respectivement. Conclusion La mortinatalite et les deces intervenant le jour de la naissance representent une fraction importante des deces perinataux et neonataux, ce qui met en lumiere la necessite urgente d'ameliorer la couverture des naissances par des accoucheurs competents et de garantir l'acces a des soins obstetricaux d'urgence. Des interventions sanitaires visant a ameliorer les soins neonataux essentiels et les comportements en matiere de recours aux soins, en particulier pour les nouveaux-nes prematures au debut de la periode postnatale, s'imposent egalement. Objetivo Evaluar las tasas, el momento y las causas de la mortalidad neonatal y la carga de mortinatalidad en zonas rurales de Uttar Pradesh (India). Consideramos aqui las implicaciones de nuestros resultados para las intervenciones neonatales. Metodos Utilizamos entrevistas de autopsias verbales para investigar 1048 defunciones neonatales y prenatales. Resultados Se notificaron 430 casos de muerte prenatal, que suponian el 41% de todas las defunciones de la muestra. Entre los 618 nacidos vivos, el 32% de las defunciones se produjeron en el mismo dia de nacimiento, el 50% se produjeron durante los 3 primeros dias de vida, y el 71% se registraron durante la primera semana. Las causas principales de defuncion en el primer dia de vida (dia O) fueron la asfixia y los traumatismos (31%) y la prematuridad (26%). Durante los dias 1 a 6, las causas mas frecuentes de muerte fueron la prematuridad (30%) y una septicemia o neumonia (25%). La mitad de todas las defunciones por septicemia o neumonia se produjeron durante la primera semana de vida. La proporcion de defunciones atribuidas a septicemia o neumonia aumento al 45% y el 36% durante los dias 7-13 y 14-27, respectivamente. Conclusion Las muertes prenatales o en el primer dia de vida representan una gran proporcion de las defunciones perinatales y neonatales, lo que pone de manifiesto la necesidad urgente de mejorar la cobertura con parteras calificadas y de garantizar el acceso a la atencion obstetrica de urgencia. Tambien es necesario implementar intervenciones de salud que mejoren la atencion neonatal basica y el comportamiento de busqueda de atencion, en particular para los recien nacidos prematuros en el periodo posnatal temprano., Introduction Every year, there are an estimated 4 million neonatal deaths, accounting for almost 40% of deaths in children younger than 5 years. (l,2) About a quarter of global neonatal [...]

Objective: To investigate the influences of size at birth, breastfeeding and morbidity on growth during infancy in poor areas of urban Bangladesh. Design: This was a prospective observational study of a cohort of newborn infants followed until 12 months of age. Setting: Slum areas of Dhaka City in Bangladesh. Subjects: A total of 1654 newborn infants were enrolled at birth, and follow-up was completed for 1207 infants. Repeated anthropometric measurements and interviews of caretakers on infant feeding and morbidity were conducted. A mixed effects regression method was used for modeling infant growth. Results: After adjusting for other variables, mean differences in body weight by birth weight and length, small-for- gestational age and prematurity categories remained relatively constant throughout infancy. A positive impact of exclusive breastfeeding in the first 3-5 months on infant growth was detectable at 12 months of age. Although the bigger babies in the sample tended to grow relatively even bigger; exclusive breastfeeding appeared to counteract this pattern. Reported diarrhoea was associated with lower body weights and lengths even after adjusting for feeding patterns. Conclusions: Size at birth has an important role in determining growth during infancy. Effective strategies for improving birth weight, poorly addressed till now in Bangladesh, are needed. The sustained effect on growth and the even more beneficial effect in lighter infants are compelling reasons for promotion of exclusive breastfeeding in early infancy. Descriptors: infant growth; birth weight; fetal growth retardation; gestational age; breastfeeding; morbidity; Bangladesh, Introduction Size at birth is an important determinant of infant growth in both developed and developing countries (Huttly et al, 1990; Adair, 1989; Binkin et al, 1988; Victora et al, [...]

The object of this study was to assess the ability of pallor and other clinical signs, including those in the Integrated Management of Childhood Illness (IMCI) guidelines developed by WHO and UNICEF, to identify severe anaemia and some anaemia in developing country settings with and without malaria. A total of 1226 and 668 children aged 2 months to 5 years were prospectively sampled from patients presenting at, respectively, a district hospital in rural Uganda and a children's hospital in Dhaka, Bangladesh. The study physicians obtained a standardized history and carried out a physical examination that included pallor, signs of respiratory distress, and the remaining IMCI referral signs. The haematocrit or haemoglobin level was determined in all children with conjunctival or palmar pallor, and in a sample of the rest. Children with a blood level measurement and assessment of pallor at both sites were included in the anaemia analysis. Using the haematocrit or haemoglobin level as the reference standard, the correctness of assessments using severe and some pallor and other clinical signs in classifying severe and some anaemia was determined. While the full IMCI process would have referred most of the children in Uganda and nearly all the children in Bangladesh with severe anaemia to hospital, few would have received a diagnosis of severe anaemia. Severe palmar and conjunctival pallor, individually and together, had 10-50% sensitivity and 99% specificity for severe anaemia; the addition of grunting increased the sensitivity to 37-80% while maintaining a reasonable positive predictive value. Palmar pallor did not work as well as conjunctival pallor in Bangladesh for the detection for severe or some anaemia. Combining "conjunctival or palmar pallor" detected 7187% of moderate anaemia and half or more of mild anaemia. About half the children with no anaemia were incorrectly classified as having "moderate or mild" anaemia. Anaemia was more easily diagnosed in Uganda in children with malaria. Our results show that simple clinical signs can correctly classify the anaemia status of most children. Grunting may serve as a useful adjunct to pallor in the diagnosis of severe anaemia. Conjunctival pallor should be added to the IMCI anaemia box, or the guidelines need to be adapted in regions where palmar pallor may not readily be detected., Introduction Anaemia, which is common in young children in developing countries in areas of both high and low malaria prevalence (1, 2), is most often caused by nutritional iron deficiency, [...]

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., Introduction 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 [...]

Bringing together various disease-specific guidelines for sick children, WHO and UNICEF have developed an Integrated Management of Childhood Illness (IMCI) algorithm, one component of which (assess and classify) was tested in the outpatient department of a rural district hospital in western Uganda. Children aged 2-59 months were seen first by a Ugandan medical assistant trained in IMCI and then evaluated by a medical officer. Sensitivity, specificity and positive predictive values were determined by comparing the IMCI classifications with a reference standard based on the medical officers' diagnoses and laboratory tests. Of the 1226 children seen, 69% were classified into more than one symptom category, 7% were not classified in any symptom category, 8% had a danger sign, and 16% were classified into a severe category, for which the IMCI approach recommended urgent hospital referral. Specificity for most classifications was good, though sensitivity and positive predictive values were variable. We conclude that the IMCI algorithm is an important advance in the primary care of sick children in developing countries., Introduction In developing countries, five diseases (pneumonia, diarrhoea, malaria, measles and malnutrition) cause the majority of deaths in under-5-year-old children. Specific programmes have reduced the mortality from respiratory infections, diarrhoea [...]

Improvement in the nutritional and cell-mediated immune status in rural Bangladeshi children will lower the rates of acute lower respiratory infections (ALRI). Malnutrition determined by weight-for-height and weight-for-age status is correlated with incidence of ALRI. A one unit reduction in body weight-for-height score is related to 52% susceptibility to ALRI. The incidence of ALRI is 94% higher in anergic than in immunocompetent children. The detection and cure of ALRI, and adequate steps to prevent other diseases is necessary to decrease child mortality in developing countries.

Patterns associated with within-to-between individual variation in energy and nutrients that were used to examine relations between growth and energy intake in Peruvian infants revealed that energy intake changed with age and diet composition. Information regarding within- and between-individual variation may be used to calculate the precision of estimates of infants' intakes during certain age periods and to estimate the number of dietary studies required to make these measurements.

A study of maternal nutritional status in Bangladesh revealed the importance of improving the nutritional status of girls to enhance child survival in future generation. A proposed interim measure provides antenatal and obstetric services for mothers shorter than 145 centimeters. Shorter mothers face a greater risk of child loss due to intergenerational effects of poor childhood nutrition on females.

In a baseline study for training purposes, two indicators of acute respiratory infections (the respiratory rate (RR) and chest indrawing) were assessed by Ministry of Health physicians in Egypt using a WHO test videotape. Chest indrawing, as defined by the WHO Acute Respiratory Infections (ARI) programme, was not widely recognized by current health personnel. Viewing a WHO training videotape led to significantly more correct assessments of chest indrawing compared with a group that had not viewed this videotape. The accuracy of using a timer versus a watch, and a 30-second versus 60-second counting interval was also evaluated. Rates counted over 60 seconds were more accurate than 30-second counts although the difference between them was not clinically significant. Counting of rates using timers with audible cues was comparable to using watches with second hands. Careful training of primary health workers in the assessment of RR and chest indrawing is essential if these clinical findings are to be used as reliable indicators in pneumonia treatment algorithms., Introduction Timely treatment of acute lower respiratory tract infections in children relies upon the assessment of clinical findings, especially respiratory rate (RR) and chest indrawing. Elevated RR has been shown [...]

The effect of vitamin A therapy on the severity and duration of acute episodes of non-cholera, watery diarrhea was studied in clinical trials conducted on 83 children afflicted by diarrhea. It was shown that the administration of vitamin A has no effect on the nutritional status and severity of the diarrhea and can thus be given safely to augment hepatic reserves during diarrheal illness.

While knowledge of causes of deaths is important for health sector planning, little is known from conventional sources about the causes of deaths in Bangladesh. This is partly due to deficiencies in the registration system and partly because few deaths are attended by qualified physicians. The present study was undertaken to update the information available on causes of deaths among under-5-year-olds, taking advantage of advances in verbal autopsy methodology and of the national Bangladesh Demographic and Health Survey conducted in 1993-94. About 25% of the deaths were associated with acute lower respiratory infections (ALRI) and about 20% with diarrhoea. Neonatal tetanus and measles remained important causes of death, and drowning was a major cause for 1-4-year-olds. Research and programmes to enable mothers to identify ALRI cases, particularly pneumonia, and to encourage timely and appropriate care-seeking and strengthening of ALRI case management at the primary care facilities are important priorities. While promotion of oral rehydration for watery diarrhoea and antibiotic treatment for dysentery should continue, broader preventive interventions including provision of safe water and sanitation, and improvements in personal hygiene require more attention. Further intensification of immunization programmes and innovative experimental interventions to reduce childhood deaths from drowning should be designed and tested., Introduction Knowledge of causes of death, at least as it relates to major available interventions, is important for health sector planning. Little is known from conventional sources about the causes [...]

A household survey, conducted in three rural sub-districts of northeastern Bangladesh, revealed a markedly lower neonatal mortality rate (NMR) in one sub-district compared to two adjacent sub-districts. This study examines the degree to which the differential in NMR can be explained by factors that could be improved by maternal and newborn health programmes, such as knowledge of danger signs and use of antenatal, delivery, and postnatal care. Use of a skilled birth attendant in uncomplicated deliveries, mothers' knowledge of newborn complications, and use of health care for sick newborns accounted for 32% of the differential in NMR. Pregnancy and delivery complications were associated with increased risk of neonatal mortality, and distance to nearest emergency obstetric care facility was significantly associated with lower risk of neonatal mortality. Therefore, health programmes to improve mothers' knowledge of newborn complications, to increase access to emergency obstetric care, and to promote appropriate use of health care could significantly reduce neonatal mortality in impoverished communities. [ABSTRACT FROM AUTHOR]

Aim: The aim of the present study, which was undertaken as a sub-study within a randomized controlled trial of zinc supplementation, was to evaluate the effect of prolonged zinc supplementation on copper status as assessed by hematological markers.Methods: Plasma copper and zinc were estimated at baseline and after 120 d of supplementation in a randomly selected infant subset (115) of the children. Of these, 61 children were in a zinc group (Z) getting 10 mg of elemental zinc, and 54 were in a control group (C) getting supplement without zinc.Results: Baseline plasma zinc was comparable in the two groups; post-supplementation zinc was significantly higher (Z 93.0 +/- 3.6 vs C 60.6 +/- 8.0) in the zinc supplementation group. There was no significant difference in the mean/median copper levels between the zinc and control groups. The percentage of children with plasma copper <100 microg/dl was also not significantly different between groups (baseline Z 14.8%, C 11.1%; post-supplementation Z 18.0%, C 11.1%). There were no differences between the zinc and control groups after 120 d of supplementation in hemoglobin (Hgb), mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), or number of lymphocytes or granulocytes.Conclusion: Zinc supplementation of 10 mg/d for 4 mo in this study did not affect copper status, as assessed by plasma copper concentration and hematological parameters, diagnostics of copper deficiency. [ABSTRACT FROM AUTHOR]

Aim: Low referral completion rates in developing countries undermine the Integrated Management of Childhood Illness (IMCI) strategy for lowering child mortality. This study sought to identify factors constraining adherence to referral advice in a health system using the IMCI approach.Methods: Caregivers of 160 children urgently referred to hospital were prospectively interviewed. Caregivers who accessed and did not access hospital were compared for potential referral constraining factors, including demographics, family dynamics, the severity of their child's illness, their interaction with the health system, self-perceived problems, and physical and financial access.Results: 67/160 (42%) referred children did not access hospital. Six factors were associated with non-access, including two health worker actions: not being given a referral slip [adjusted odds ratio (OR)= 15.3, 95% confidence interval (95% CI) 4.4-64.6] and not being told to go to the hospital immediately (adjusted OR = 5.3, 95% CI 1.9-16.3). Receiving both of these interventions reduced the risk of not accessing hospital to 19%, from 96% for those who received neither intervention. Several indicators of illness severity, including caregivers' ranking of their children's illness severity, the presence of severe illness signs and mortality, were investigated and found not to be important explanatory factors.Conclusion: Providing a referral slip and counseling the caregivers of severely ill children to go to the hospital immediately appear to be powerful tools for increasing successful referral outcomes. [ABSTRACT FROM AUTHOR]