Evaluation of the utility of IMNCI algorithm in predicting illness, hospitalization, and management of children aged 2 months to 5 years in a tertiary referral centre

Background: India has around 240 million under-five children and contributes close to 25% of under-five mortality. About 70% of such deaths are due to diarrhea, pneumonia, measles, malaria or malnutrition and often a combination of these conditions. These are also the diseases that are seen to afflict three out of every four sick children seeking care at a health facility. Aim of the study: To evaluate the utility of the WHO / UNICEF guidelines for “Integrated Management of Neonatal and Childhood Illness” among children aged two months to five years attending an Urban center. Materials and methods: This Prospective observational study was did in the outpatient department and emergency room, The Institute of child Health and Hospital for Children, Egmore, Chennai. Children attending the outpatient department and emergency room aged between 2 months and 5 years for the first time for a fresh complaint due to any illness were included in the study. Each study subject was assessed and classified according to IMNCI guidelines and the treatment options were identified and recorded in a proforma. Each child was evaluated using IMNCI algorithms for high Venkatesh Periasami, Senthilkumar Palanivelu. Evaluation of the utility of IMNCI algorithm in predicting illness, hospitalization, and management of children aged 2 months to 5 years in a tertiary referral centre. IAIM, 2019; 6(3): 73-82. Page 74 malaria risk areas and low malaria risk areas. The IMNCI algorithm was split into four modules dealing with specific complaints (cough/breathing difficulty, diarrhea, fever, ear problems) and the classification and treatment options arrived at for each child on applying the specific split algorithms guided by the presenting complaints were also noted. Results: 517 complaints were reported by the parents/other caregivers accompanying the children enrolled in the study; an average of 1.72 complaints per child. depicts the frequency of these symptoms. Over 43% (227) of such complaints comprised of respiratory problems such as cough or difficulty in breathing. One-fourth of all presenting complaints (125) were fever and another 10% (56) consisted of loose or bloody/mucoid stools. Other complaints frequently reported were convulsions (15, 2.9%), vomiting everything (14, 2.7%), lethargy/unconsciousness (11, 2.1%), not being able to drink/breastfeed (11, 2.1%) and ear problems (9, 1.7%). Conclusion: Multiple diagnoses are the rule than an exception in under five sick children. Hence vertical, disease-specific algorithms are inappropriate in the evaluation and management of a sick child. Integrated approaches must be preferred. The IMNCI algorithm can address most complaints that sick children present with. When implemented by health workers with appropriate training, the referral criteria of IMNCI are fairly good predictors of serious illness which requires medical attention.

Assessment of Breastfeeding Practices: Findings from Urban Slum Area at Ahmedabad City, India.

Introduction: Correct breast feeding technique, proper position and attachment are very important to get all benefits of breast feeding. Integrated Management of Neonatal and Childhood Illness (IMNCI) has also given utmost importance to the correct breast feeding technique. Objectives: To describe the socio-demographic profile and feeding practices among lactating mothers, to identify factors associated with good breast feeding (attachment) practices and to evaluate the impact of video demonstration on breast feeding practices immediately after and at one month follow up. Methodology: An interventional study was conducted at urban slums of Ahmedabad city, India. Results from 150 lactating mothers were analysed. Interactive sessions in conjunction with video demonstrations of IMNCI regarding correct breast feeding techniques were conducted among 9 groups of lactating mothers. Number of lactating mothers in each group varied from 15 to 20. Good signs of attachment were measured pre IMNCI video sessions, immediately and one month after the session. Results: Mean age of mothers was 26.44 years. Total mothers who had more than 6 antenatal visits were 59.3%. Two-thirds of lactating mothers did not receive any kind of breast feeding related advice. Only 8.0% had initiated breast feeding after 48 hours of delivery. Some kind of pre lacteal feed was given to 41.3% of the newborns. Improvement in all four signs of good attachment (mouth widely open, lower lip turned outward, chin touching the breast and dark skin seen more above than below areola) was seen among lactating mothers while feeding their babies after training session. Mothers from higher social class and with education > 12 standard and mothers who have received advice during antenatal and postnatal period regarding breast feeding were found to have significant positive impact on determining good attachment while breast feeding. Conclusion: Breast feeding related counseling should be continued at frequent interval during post natal period, so that lactating mothers can follow correct breastfeeding practices.

Rapid assessment of IMNCI programme in Bhavnagar District, Gujarat.

Background & Objectives: The desired impact of IMNCI is the reduction of mortality, morbidity and suffering, through assuring children’s access to quality health care in health facilities and improved case management at home. Maintaining the performance of health and village workers is essential to achieve this impact. So objective of this study is to assess IMNCI implementation in Bhavnagar district of Gujarat to strategize for accelerating effective implementation. Methods: A cross sectional study was carried out in March 2012 in Bhavnagar district. Four blocks of Bhavnagar district were purposefully selected out of seven blocks on the basis of immunization coverage of previous year. From each block one best PHC and from selected PHC one best sub-centre and one best Anganwadi were selected purposefully by solely on basis of perception of Medical Officer in charge PHC and BHO for implementation of IMNCI in their area in last one year. The purpose of adopting such method was to evaluate the performance of IMNCI implementation in centres (PHC, SC, AW) that was judged best by their supervisors. After selection, PHC, SC and Anganwadi centre were visited to assess the practice of IMNCI by ANM and Anganwadi Worker. Medical Officer, Health Supervisors and ICDS officers were interviewed to understand overall implementation process. For collecting data pre-tested and predesigned questionnaire was utilized. Results: Basic IMNCI training in Bhavnagar was completed in 90% of health and ICDS workers. More than 87.5% workers said that their knowledge, skill, confidence and credibility among community were increased after IMNCI training. Logistic and drugs supply were insufficient at sub centre and Anganwadi centre. Out of the total 80 filled IMNCI case sheets by the health and ICDS workers, 32(40%) were found accurately complete as the correctly filling of all the column (assessment and classification and treatment) in form considered as complete form. Accurate classification, management and advice of cases according to IMNCI guidelines were 62 (77.5%), 42 (52.5%) and 38 (47.5%) respectively as the accurate classification (assessment, classification and treatment) of the entire column in form correctly. Combination of one correct and other incorrect assessment or classification or treatment considered as partial accurate and inaccurate if all the column were not assessed or not classified or not given the treatment correctly. While observing actual practice of IMNCI, accuracy among health and ICDS workers was found in assessment 5(31.3%), Classification 8(50%) and treatment 7(43.8%). Supportive supervision and feedback mechanism were lacking at all level. Interpretation & Conclusion: Supportive supervision and feedback mechanism are key concern and must address. Proper logistic and drugs planning and management also main concern for IMNCI programme.

Pre-service training of IMNCI in medical colleges – MUHS experience.

Background: IMNCI training improves knowledge and skills in newborn and child health care. If adopted in pre service training, this will help in improvising the health system. Objectives: To investigate the opinion and effectiveness of in-service training of IMNCI and impact on medical college teachers and students which will reflect on their management and care of the seriously ill newborn or child at community set up. So It was decided to take feedback of the students and medical college teachers who have undergone IMNCI training. Methodology: 115 students and 36 medical college teachers were given prevalidated questionnaire to test knowledge, methodology and open comments about IMNCI. Questionnaire with 30 items was designed to know feedback about IMNCI Training. Results: It was found that the 66 % were satisfied with IMNCI training, 50 % use IMNCI in practice,72% knew principles of IMNCI and 91% understood assessment of the children based on IMNCI guidelines, colour coded system and components of IMNCI. Introducing IMNCI in syllabus and textbooks may improve usage of IMNCI in practice. The students felt color coded system of IMNCI will help in early referral. Integration at field and in other subjects was appreciated and students wanted more hands on training at hospital and field level. Only 25% medical college teachers who have undergone F IMNCI training felt it is better than IMNCI which includes protocol based and skill based workshop. Conclusion: IMNCI and FIMNCI adopted in pre service training will improve skill and knowledge of health professionals.

Validation of IMNCI Algorithm for Young Infants (0-2 months) in India.

Objective: To check the validity of Integrated Management of Neonatal and Childhood Illness (IMNCI) algorithm for young infants (0-2 months). Design: Prospective observational study. Setting: The outpatient department and emergency room of a medical college attached hospital. Methods: 419 infants (176 between 0-7 days, 243 between 7 days–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. Results: 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–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. Conclusion: IMNCI algorithm for evaluation and management of young infants has good sensitivity and specificity for referring cases with severe illness.

Effect of IMNCI training in urban and rural communities on use of commercial feeding formula.

Background: Exclusive breastfeeding for the first six months of life is the single most important child survival intervention, the Eleventh Five Year Plan will concentrate on promoting optimal breastfeeding practices among women at home and in health facilities .The present study was, therefore, conducted to assess the use of Commercial Formula and breast Feeding among the rural & urban community of Ahmedabad district.Material and Method: This study was carried out in Urban and Rural communities of Ahmedabad District. Grade I PEM was seen in 138 (45.5%) Grade II in 126 (41.59%) & Grade III in 12 (03.96%) children. In the present study showed that out of total 603 children were studied in the age group of 0-24 months. Result and Discussion: In study group 19.16 % were from 0-6 months while 43.64% of children were of 7-12 months of age. 287 (95.66%) mother said that breast-feeding started immediately after birth. 234 (78.00%) mother said that commercial weaning food are not more nutritious than breast milk. While for rural areas, Almost 262(86.46%) mother had correct knowledge that breast feeding is given up to 4-5 month of age. 293 (96.70%) mother said that breast-feeding started immediately after birth. The difference of the feeding practice of urban rural area was found statically significant. These finding of our study were compared with the findings of District Level Household Survey-3(DLHS3) which shows significant improvement in the immunization in both urban & rural areas.

Primary health care and child survival in India.

The Primary Health Care (PHC) has been globally promoted as a comprehensive approach to achieve optimal health status and ‘Health for all’. The PHC approach, although, initially received the attention but failed to meet the expectations of the people in India. The child health programs in India had been started for long as verticals programs, which later on integrated and had been planned in a way to deliver the services through the PHC systems. Nevertheless, the last decade has witnessed many new initiatives for improving child health, specially; a number of strategies under National Rural Health Mission have been implemented to improve child survival- Skilled Birth Attendant and Emergency Obstetric Care, Home Based Newborn Care, Sick newborn care units, Integrated Management of Neonatal and Childhood Illnesses, strengthening Immunization services, setting up Nutritional rehabilitation centers etc. However, for a large proportion of rural population, an effective and efficient PHC system is the only way for service delivery, which still needs more attention. The authors note that although there have been improvements in infrastructure, community level health workers, and availability of the funding etc., the areas like community participation, district level health planning, data for action, inter-sectoral coordination, political commitment, public private partnership, accountability, and the improving health work force and need immediate attention, to strengthen the PHC system in the country, making it more child friendly and contributory in child survival, in India.

Childhood morbidity, household practices and health care seeking for sick children in a tribal district of Maharashtra, India.

Objectives: To find out the magnitude of childhood morbidities, health care seeking behavior and explore the status of 'some desired practices' at household level during episodes of illness in two tribal blocks of Chandrapur district. Materials and Methods: The present explanatory mixed-method design of quantitative (survey) and qualitative (focus group discussions, FGDs )methods was undertaken in nine Primary health centers of Warora and Bhadrawati blocks in Chandrapur district. The information of 2,700 under-five children on morbidity, health care seeking behavior and some desired practices at household level was collected by paying home visits and using pre-designed and pre-tested questionnaire. The data was entered and analyzed by using SPSS 12.0.1 and C sample program of epi_info (version 6.04d) software package. The conventional content analysis of FGD data was undertaken. Results: The prevalence of morbidities was high among newborns and children. About 1,811 (67%) children had at least one of the morbidities. Private health care providers and village level faith healers were preferred for seeking treatment of newborn danger sings and childhood morbidities. The status of some desired household practices such as frequent feeding and giving extra fluid to drink during episodes of illness was poor. Conclusions: In conclusion, considering high prevalence of child morbidities and poor status of some desired household practices of caregivers at household level for sick children, household and community IMNCI strategy needs to be implemented to promote child health and nutrition. Apart from this, health care delivery at village level should be strengthened.