Despite recent overall improvement in the under-five mortality worldwide, young infant mortality remains a serious problem, accounting for an increasing proportion of child deaths in resource-poor countries.1 2
Most young infant deaths continue to occur in homes with unwillingness, inability or delay in care seeking precluding appropriate referral of severely ill infants to adequately resourced health facilities.3
When healthcare is sought primary and even secondary health facilities (rural hospitals) in resource-poor countries often have no specialists (such as paediatricians) and limited or no laboratory diagnostic capability.4
In such settings, clinical decisions for appropriate management of severely ill infants have to be made on the basis of presenting clinical signs and symptoms alone. Typically health workers providing immediate care in these settings (even non-specialist physicians) have had as little as 2–3 weeks instruction in the care of the sick newborn in basic training courses lasting 2–5 years.
So which clinical symptoms and signs are the most useful in such settings for identifying serious illness in this vulnerable group of patients? The current Kenyan adaptation of the World Health Organisation (WHO) Integrated Management of Childhood Illness (IMCI) algorithm recommends a panel of 15 clinical signs and symptoms for the identification of possible severe disease in infants aged 0–59 days (ie, young infants).5
The current panel of signs was based on the WHO multicentre study of clinical features and causes of serious bacterial infections in young infants.6
Training health workers to identify large numbers of signs and then using an algorithm based on all these signs in often busy clinics in resource-poor settings may threaten feasibility of implementation. We therefore sought to summarise the evidence available on clinical predictors of serious illnesses to help define a likely minimum set of signs that would be most useful in revised Kenyan national guidelines for the hospital care component of IMCI named Emergency Triage, Assessment, and Treatment plus Admission Care (ETAT+)7 8
and potentially to broader child survival programs such as the WHO's IMCI approach.
The clinical question addressed was: In sick young infants aged 0–59 days brought to a healthcare worker, which clinical signs, alone or in combination, are most useful at indicating the presence of severe disease warranting referral-level care or hospitalisation for interventions that might include: parenteral antibiotics, parenteral fluids, assisted feeding, oxygen therapy, etc.? In particular, our interest was to identify a minimum set of clinical features that might best: (1) predict the need for treatment of potentially severe infection; (2) usefully limit the number and variety of clinical indicators health workers must be aware of that would comprise a basic, minimum standard for knowledge, clinical assessment and management; (3) help identify ill young infants for more specialist review if this is available.
Our interest was not therefore to identify all the clinical symptoms and signs that may be associated with serious illness in those aged 0–59 days. Rather the emphasis is on those signs and symptoms which most efficiently and effectively identify young infants at risk of severe disease after excluding those with prematurity, very low birthweight or severe jaundice. We reasoned that such a minimum set of signs and symptoms should form the basis of practice, in managing possible neonatal sepsis in particular, for those with limited training or experience in young infant care if more specialist review is not available.