|Year : 2011 | Volume
| Issue : 4 | Page : 324-328
Study comparing the management decisions by IMNCI algorithm and pediatricians in a teaching hospital for the young infants between 0 to 2 months
Agnihotri Bhattacharyya1, Sanjay Kumar Saha1, Pramit Ghosh2, Chitra Chatterjee3, Samir Dasgupta4
1 Demonstrator, Department of Community Medicine, Bankura Sammilani Medical College, Bankura, India
2 Assistant Professor, Department of Community Medicine, Medical College, Kolkata, India
3 Associate Professor, Department of Community Medicine, College of Medicine and Jawaharlal Nehru Memorial Medical Hospital, Kalyani, WBUHS, India
4 Professor and Head, Department of Community Medicine, Medical College, Kolkata, India
|Date of Web Publication||30-Jan-2012|
Tobin Road, Rajpur, P.O. Rajpur, 24 PGS(S), West Bengal – 700 149
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Integrated management of neonatal and childhood illness (IMNCI) was already operational in many states of India, but there were very few studies in Indian scenario comparing its validity and reliability with the decisions of pediatricians. The general objective of the study is to compare the IMNCI decisions with the decisions of pediatricians and the specific objectives are to assess the agreement between IMNCI decisions and the decisions of pediatricians, to assess the under diagnosis and over diagnosis in IMNCI algorithm in comparison to the decisions of pediatricians and to assess the significance of multiple presenting symptoms in IMNCI algorithm. The study was conducted among the sick young infants presenting in pediatric department from January to March 2009. The IMNCI decision was compared with pediatrician's decisions by percent agreement, Kappa and weighted Kappa with the aids of SPSS version 10. The overall diagnostic agreement between IMNCI algorithm and pediatrician's decisions was 55.56%, (Kappa 0.32 and weighted Kappa 0.41) with 33.33% over diagnosis, and 11.11% under diagnosis. 71.88% young infants with multiple symptoms and 40% with single symptom were classified as red by IMNCI algorithm, which is statistically significant (P=0.004) whereas 56.25% young infants with multiple and 31.76% with single symptom were considered admissible by pediatricians, which is not statistically significant (P=0.052).
Keywords: Integrated management of neonatal and childhood illness algorithm, Pediatrician′s decision, Under and over diagnosis
|How to cite this article:|
Bhattacharyya A, Saha SK, Ghosh P, Chatterjee C, Dasgupta S. Study comparing the management decisions by IMNCI algorithm and pediatricians in a teaching hospital for the young infants between 0 to 2 months. Indian J Public Health 2011;55:324-8
|How to cite this URL:|
Bhattacharyya A, Saha SK, Ghosh P, Chatterjee C, Dasgupta S. Study comparing the management decisions by IMNCI algorithm and pediatricians in a teaching hospital for the young infants between 0 to 2 months. Indian J Public Health [serial online] 2011 [cited 2019 Nov 13];55:324-8. Available from: http://www.ijph.in/text.asp?2011/55/4/324/92418
Survival and quality of life of children is an indicator of development in any country. Infant mortality rate (IMR) is an important indicator of physical quality of life index (PQLI) and it is also a sensitive indicator of availability, utilization and effectiveness of health care, particularly perinatal care.  Every year more than 10 million children die in low- and middle-income countries including India before they reach their fifth birthday and seven out of ten of these deaths are due to some common treatable or preventable conditions like diarrheal dehydration, acute respiratory infections, measles, malaria, and malnutrition.  Delay in seeking treatment and lack of quality care in health facilities are also important causes of death in such conditions. 
It was also seen that the children brought for medical treatment are often suffering from multiple conditions and require a comprehensive health care and syndromic approach, based on common signs and symptoms for successful treatment. , Moreover according to the World Bank Report 1993, in situations where laboratory support and clinical resources are limited, a syndromic approach with comprehensive health care strategies is more realistic and cost-effective.  It has also the potential to make the greatest impact on the global burden of disease.  Considering those situations, during the year 1992, WHO, in collaboration with UNICEF and some other agencies, institutions and individuals, responded to the challenge by adopting a strategy known as integrated management of childhood illness (IMCI). 
The Government of India along with other experts also recognized the need for a strategy like IMCI. Moreover, as in Indian scenario neonatal mortality constitutes a substantial (64%) proportion of under five mortality, all neonates, starting from the day of birth were included in the strategy. Thus for Indian version, IMCI was adapted as Integrated Management of Neonatal and Childhood Illness (IMNCI). 
A study by Gupta et al.,  done at Maulana azad Medical College during 1999-2000, compared the decisions of IMCI algorithm with that of pediatricians in the age group one week- two month. Deorari, et at.,  have tested the predictability of hospital admission for some common signs and symptoms at Safdarjung Hospital, New Delhi in the year 2007. But there is paucity of published study in West Bengal although IMNCI has been already implemented in Purulia district since 2008.
The general objective of the study is to compare the IMNCI decisions with the decisions of pediatricians with the specific objectives being to assess the agreement between IMNCI decisions and the decisions of pediatricians, to assess the under diagnosis and over diagnosis in IMNCI algorithm in comparison to the decisions of pediatricians and to assess the significance of multiple presenting symptoms in IMNCI algorithm
This observational, cross-sectional study was conducted in the Department of Pediatrics, Medical College, Kolkata from January to March 2009. All young infants (0-2 months) with a fresh episode of illness presented during the study period in the Department of Pediatrics were included. The number of the young infants was 117. Mother or other caregivers were interviewed with a pre-designed, pre-tested, semi-structured schedule and the young infants were examined according to the IMNCI algorithm using the Physician's chart booklet for age group (0-2 months). They were classified and categorized according to the severity using the color code, like red (urgent referral), yellow (treatment in the same health facility) or green (treatment at home). The color code was recorded.
After this assessment, those infants were sent to pediatricians and as in any tertiary care hospital, all of them were examined by the pediatricians. Pediatricians recorded the presenting symptoms, clinical features, provisional diagnosis and their decision for management in the OPD or emergency tickets, from where the presenting symptoms and their decision for management were recorded.
The decisions of the pediatricians were compared with the decision by the IMNCI algorithm. The data were analyzed using standard statistical technique with the help of software SPSS version 10 windows compatible. The comparison was done by statistical calculations like percent agreement, Kappa, and weighted Kappa. ,
In the present study, the criteria of comparison were as follows:
So in the above example the cases present in the cells a , e and i were considered to show agreement. The cases in the cells b, where IMNCI decisions were urgent referral (color code red), but pediatricians considered investigation, treatment and follow up, c , where IMNCI decisions were urgent referral (color code red), but pediatricians considered home treatment only and f , where IMNCI decisions were treatment in the same health facility (color code yellow) but pediatricians considered home treatment only were considered to show over diagnosis. The cases in the cells d, where IMNCI decisions were treatment in the same health facility (color code yellow) but pediatricians considered admission and treatment, g , where IMNCI decisions were treatment at home (color code green) but pediatricians considered admission and treatment and h, where IMNCI decisions were treatment at home (color code green but pediatricians considered investigation, treatment and follow up were considered to show under diagnosis.
The number of study subjects was 117. Among them 3(2.56%) presented within 24 h of birth; 27(23.08%) were between 1 to 7 days of age; 38(32.48%) were between 8 days to 4 weeks and 49(41.88%) were in the age group 5-8 weeks. 60.68% of the young infants were males. Deorari et al.,  in his study on clinico- epidemiological profile and predictors of severe illness in the age group below 60 days using the IMNCI protocol at Safdarjung hospital and AIIMS, New Delhi in the year 2007 had seen 11% of young infants were within seven days of age.
All the young infants were examined, classified and categorized according to severity using the IMNCI algorithm. The severity was recorded according to the color code as red, yellow or green. In the present study, 57 young infants (48.72%) were categorized as red; whereas in the study done by Gupta et al.,  59% young infants were categorized as red. In case of pediatrician's decisions 45 young infants (38.46%) were considered for hospitalization in the present study, whereas Gupta et al.,  had found it as 65.7%. The difference in result could be due to the different study setting.
The IMNCI decisions were compared with the pediatrician's decisions and it was revealed that the overall diagnostic agreement was 55.56%, and among the disagreements, 33.33% was due to over diagnosis, and 11.11% was due to under diagnosis. After analysis of overall agreement, chance agreement was excluded by Kappa test. Simple Kappa value was 0.32 [Table 1], suggesting minimal agreement.  As here the categories were not merely nominal, simple Kappa test was not the sufficient one  (as mentioned in methodology) and weighted Kappa test was done. The weighted Kappa value was 0.41 [Table 1] suggesting fair agreement.  The agreement was 59.7% in the study done by Gupta et al.,  with 20.9% under diagnosis and 19.4% over diagnosis. Therefore, the mismatch was more due to over diagnosis than under diagnosis.
|Table 1: Distribution of study subjects (0-2 months) according to comparison between decision of IMNCI algorithm and pediatrician's decisions (n=117)|
Click here to view
When the conditions responsible for diagnostic discordance were thoroughly searched, it was found that there were 13 cases of under diagnosis [Table 1]. Among those, six cases were considered admissible by the pediatricians, though classified in the yellow category by the IMNCI algorithm. Those cases were two cases of jaundice, one case each for congenital leukemia, anorectal malformation, hemorrhagic disease of newborn and septicemia. There were two other cases, classified as green by the algorithm, like one case of birth asphyxia and one case of lower respiratory tract infection, where pediatricians advised admission. Other five cases, with four cases of lactose intolerance and one case of congenital hypothyroidism, were classified in the green category by the algorithm; but pediatricians advised investigation, treatment and follow up in those conditions.
There were 39 cases of over diagnosis and among them 20 were in the red category, where in five cases pediatricians considered investigation, treatment and follow up. These cases were one case each of lower respiratory tract infection, upper respiratory tract infection, low birth weight baby, common cold, and Down's syndrome. Those cases were included in red category due to presence of severe malnutrition or increased respiratory rate, lethargy (possible serious bacterial infection).
In another fifteen cases in red category, pediatricians considered home treatment only. These cases were five cases of low birth weight baby, three cases of common cold, two cases of upper respiratory tract infection, two cases of thrush, two cases of skin infection, and one case of abdominal colic. Inclusion in red category was due to presence of severe malnutrition or increased respiratory rate, lethargy (possible serious bacterial infection).
Similarly for another nineteen cases, pediatricians considered home treatment only, though these cases were classified in yellow category by IMNCI algorithm. In this category, there were eight cases of common cold, five cases of upper respiratory tract infection, one case each of lactose intolerance and cephalhematoma and four babies were healthy. Inclusion in yellow category was due to consideration of low weight for age or feeding problem. In the study by Gupta et al.,  also, the major cause of over diagnosis was upper respiratory tract infection.
85(72.65%) young infants presented with single and 32(27.35%) young infants presented with two symptoms. It might be a possibility that many presenting symptoms were missed by the caregivers or mothers. In a study done in Sarojininagar Block, Uttar Pradesh, India by Awasthi et al.,  it was found that in the neonates the caregivers sometimes did not recognize even the common presenting symptoms in almost half the cases (46%).
In the present study, the young infants most commonly presented with cough and cold (33.33%). The other common presenting symptoms were fever (12.82%), loose stool (11.11%), respiratory distress (11.11%), running nose (8.55%), convulsion (7.69%) and vomiting (7.69%). There were also some other presenting symptoms like yellow discoloration of skin, difficulty in feeding, birth related problems, skin infection and abdominal pain. Gupta et al.,  also found that the most common presenting symptom was cough (65.3%), followed by fever (53.8%), running nose (40.3%), diarrhea (17.3%), respiratory distress (9.6%), vomiting (9.6%), jaundice (5.7%), constipation (3.8%) and umbilical redness (3.8%). According to Deorari et al.,  the most frequent cause of hospital admission in the age group below 7 days was hyperbilirubinemia; and in the age group between 7 to 59 days it was sepsis and pneumonia.
71.88% young infants presented with more than one symptom were in the red category, whereas only 40% young infants with single symptom fell in red category, requiring urgent referral [Table 2]. This association was statistically significant (P = 0.004).
|Table 2: Distribution of study subjects (0-2 months) according to number of presenting symptoms with comparison between decision of IMNCI algorithm and pediatrician's decision|
Click here to view
However, according to pediatricians, only 56.25% young infants with more than one symptom were considered admissible and 31.76% cases were considered admissible in the group presented with only one symptom. The association was not statistically significant (P = 0.052) [Table 2]. Therefore, though IMNCI has given due importance in presence of co morbidities but pediatricians did not consider presence of co morbidities as an important criterion for admission.
The presence study has revealed 55.56% diagnostic agreement with the decisions of pediatricians and the disagreement observed was mostly due to over diagnosis. Over diagnosis was considered desirable as it will help to identify more cases from the primary care setting for referral to the higher health facility. Presence of co morbidities was also given due importance in the IMNCI algorithm.
The study has certain limitations as it was done in a tertiary care setting, further study will be required for its validation in actual field situation particularly in primary health care setting.
| References|| |
|1.||Park K. Concept of Health and Disease. In, Textbook of Preventive and Social Medicine. 20 th ed. Jabalpur, India: M/s Banarasi Das and Bhanot Publishers; 2009. p. 25. |
|2.||Integrated management of neonatal and childhood illness. In, Student's handbook for Integrated management of neonatal and childhood illness, WHO Department of Child and Adolescent Health and Development, Ministry of Health and Family Welfare, Government of India; 2007. p. 1. |
|3.||World Health Organization. Improving Child health, the integrated approach. Report of the division of Child Health and Development 1996-1997. Geneva: WHO; 1998. p. 2-7. |
|4.||World Bank. World development report 1993: Investing in Health. New York: Oxford University Press; 1993. |
|5.||IMNCI Training Module (No.1) for MOs. New Delhi: UNICEF; May 2005. |
|6.||Child Health Programme in India - Major milestones in Child Health [Internet]. Ministry of Health and Family Welfare, Government of India. Available from: http://mohfw.nic.in/dofwwebsite/childhealth rti.pdf. [Last cited in 2009 Jun 3]. |
|7.||Gupta R, Sachdev HP, Shah D. Evaluation of the WHO / UNICEF Algorithm for Integrated management of childhood illness between the age of one week to two months. Indian Pediatr 2000;37:383-90. |
|8.||Deorari AK, Chellani H, Carlin JB, Greenwood P, Prasad MS, Satyavani A, et al. Clinicoepidemiological profile and predictors of severe illness in young infants (<60 days) reporting to a hospital in North India. Indian Pediatr 2007;44:739-48. |
|9.||Jeckel JE, Katz DL, Elmore JG. Understanding Errors in Clinical Medicine. In, Epidemiology, Biostatistics, and Preventive Medicine. 2 nd ed. Philadelphia: W. B. Saunders Company; 2001. p. 108-14. |
|10.||Viera AJ, Garrett JM. Understanding interobserver agreement: The kappa statistic. Fam Med 2005;37:360-3. |
|11.||Awasthi S, Verma T, Agarwal M. Danger signs of neonatal illnesses: Perceptions of caregivers and health workers in northern India. Bull World Health Organ 2006;84:819-26. |
[Table 1], [Table 2]
|This article has been cited by|
||Reliability and validity of pediatric triage tools evaluated in Low resource settings: a systematic review
| ||Bhakti Hansoti,Alexander Jenson,Devin Keefe,Sarah Stewart De Ramirez,Trisha Anest,Michelle Twomey,Katie Lobner,Gabor Kelen,Lee Wallis |
| ||BMC Pediatrics. 2017; 17(1) |
|[Pubmed] | [DOI]|
||Treatment of Infections in Young Infants in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis of Frontline Health Worker Diagnosis and Antibiotic Access
| ||Anne CC Lee,Aruna Chandran,Hadley K. Herbert,Naoko Kozuki,Perry Markell,Rashed Shah,Harry Campbell,Igor Rudan,Abdullah H. Baqui,Peter Byass |
| ||PLoS Medicine. 2014; 11(10): e1001741 |
|[Pubmed] | [DOI]|