A total of 3011 infants were triaged, out of which 2950 were enrolled. Of all the three age groups, 329 infants required hospitalization, and 92 were admitted. The flow of infants in the study is given in supplementary figure S1.
Table 1 shows the baseline characteristics of the enrolled infants, 55% of the infants were aged 0–6 days, 28% were aged 7–27 days and 17% were aged 28–59 days. Majority of the infants were delivered at home (78%). The most common reason for seeking care in the 0–6 days group was umbilical redness or discharge (29.2%), followed by excessive crying (11.1%). In the older age group, 16.9% infants in the 7–27 age group presented with cough, 14.1% presented with fever and 9.7% presented with diarrhea. The most common primary diagnosis (assessed by the pediatrician) in the 0–6 days group was localised infection (including skin, eye, oral and umbilical infections) 44.7%. In the older age group, the most common primary diagnosis was found to be upper respiratory tract infection (URTI), with 33.6% diagnosed infants in the 7–27 days group and 32.6% in the 28–59 days group. (Table 2)
Table 1
Baseline Clinical Characteristics of Study Groups
Characteristics | Number of infants N = 2950 |
0–6 days | 1633 | (55%) |
7–27 days | 817 | (28%) |
28–59 days | 500 | (17%) |
Male | 1467 | (50%) |
Exclusive breastfeeding | 1578 | (54%) |
Vital signs | | |
Pulse (> 160 bpm) | 30 | (1%) |
Pulse oximetry (< 95%) | 513 | (17%) |
Obstetric history | | |
Home delivery | 2298 | (78%) |
Delivered by skilled attendant | 720 | (24%) |
Low Birth Weight (< 2500 g) | 942 | (32%) |
Parity > 0 | 520 | (18%) |
Gestational age (< 37 weeks) | 59 | (2%) |
Maternal tetanus toxoid | 645 | (22%) |
Antenatal care (3 visits or more) | 624 | (21%) |
Diabetes during pregnancy | 5 | (0%) |
Anemia during pregnancy | 1049 | (36%) |
UTI during pregnancy | 35 | (1%) |
Fever at the time of delivery | 382 | (13%) |
Prolonged labor | 191 | (7%) |
Prolonged rupture of membranes | 170 | (6%) |
Vaginal delivery | 2878 | (98%) |
Data are in n(%) or mean(SD) |
Table 2
Primary diagnosis by age group for severe illness (assessed by pediatrician) and need for hospital management
| Required Admission | Did not require admission | Total infants in each age category |
Diagnosis | 0–6 days, n = 220 | 7–27 days, n = 68 | 28–59 days, n = 41 | 0–6 days, n = 1413 | 7–27 days, n = 749 | 28–59 days, n = 459 | 0–6 days, n = 1633 | 7–27 days, n = 817 | 28–59 days, n = 500 | Total 2950 |
Prematurity/ LBW | 47 (21.4) | 9 (13.2) | 4 (9.8) | 141 (9.9) | 38 (5.1) | 20 (4.4) | 188 (11.5) | 47 (5.7) | 24 (4.8) | 259 (8.7) |
Birth Asphyxia | 23 (10.4) | 0 (0.0) | 0 (0.0) | 34 (2.4) | 5 (0.7) | 2 (0.4) | 57 (3.5) | 5 (0.6) | 2 (0.4) | 64 (2.2) |
Birth Injury | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (0.1) | 2 (0.3) | 2 (0.4) | 1 (0.06) | 2 (0.2) | 2 (0.4) | 5 (0.2) |
Congenital Malformations | 2 (0.9) | 1 (1.5) | 0 (0.0) | 1 (0.1) | 1 (0.1) | 1 (0.2) | 3 (0.18) | 2 (0.2) | 1 (0.2) | 6 (0.2) |
Hyperbilirubinemia, physiological jaundice | 35 (15.9) | 5 (7.4) | 5 (12.2) | 130 (9.2) | 43 (5.7) | 14 (3.1) | 165 (10.1) | 48 (5.9) | 19 (3.8) | 232 (7.9) |
Severe infection (sepsis, pneumonia, meningitis) | 96 (43.6) | 50 (73.5) | 26 (63.4) | 0 (0.0) | 2 (0.3) | 1 (0.2) | 96 (5.9) | 52 (6.4) | 27 (5.4) | 175 (5.9) |
URTI, mild ARI | 0 (0.0) | 0 (0.0) | 0 (0.0) | 151 (10.7) | 275 (36.7) | 163 (35.5) | 151 (9.2) | 275 (33.6) | 163 (32.6) | 589 (19.9) |
Localized infections (skin, eye, umbilical, oral) | 3 (1.4) | 2 (2.9) | 2 (4.9) | 727 (51.4) | 243 (32.4) | 157 (34.2) | 730 (44.7) | 245 (29.9) | 159 (31.8) | 1134 (38.4) |
Diarrhea, dysentery, persistent diarrhea, dehydration | 0 (0.0) | 1 (1.5) | 1 (2.4) | 25 (1.8) | 68 (9.0) | 70 (15.3) | 25 (1.5) | 69 (8.4) | 71 (14.2) | 165 (5.6) |
Colic, gastrocolic reflex, regurgitation, constipation | 0 (0.0) | 0 (0.0) | 0 (0.0) | 39 (2.8) | 29 (3.9) | 13 (2.8) | 39 (2.38) | 29 (3.5) | 13 (2.6) | 81 (2.7) |
Others | 14 (6.4) | 0 (0.0) | 3 (7.3) | 163 (11.5) | 38 (5.1) | 13 (2.8) | 177 (10.8) | 38 (4.6) | 16 (3.2) | 231 (7.8) |
Well baby | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (0.1) | 5 (0.7) | 3 (0.7) | 1 (0.06) | 5 (0.6) | 3 (0.6) | 9 (0.3) |
Data is shown as n(%) |
Supplementary Table s1 describes the individual signs and symptoms in predicting the need for hospitalization in each age group. History of fever, history of no cry at birth, respiratory rate > 60 breaths per minute and redness and pus around the umbilicus emerged as the most prevalent signs in the 0–6 days group. In the older groups, history of fever remained the most prevalent sign. We compared the point estimates of odds ratios for different signs and symptoms. Among the most common signs (prevalence more than 10%), signs such as moving only on stimulation, lethargy, severe chest indrawing, and nasal flaring appeared as having the greatest odds of predicting severe illness requiring hospitalization in the 0–6 days group, while in the older age groups, movement only on stimulation and prolonged capillary refill had higher odds as compared to other signs and symptoms in the group.
We used the WHO algorithm for young infants for evaluating the effectiveness of signs in the Pakistani population [8]. As reported in the main paper, we reported an identical sensitivity of 85.9% and specificity of 71.6% in the 0-6-day age group. The same model was applied to the older age groups. In the 7–27 days age group, the algorithm had a sensitivity of 72.4% and a specificity of 83.1% while in the 28–59 days group, it had a sensitivity of 80.5% and a specificity of 80.2%. Sensitivity and specificity of each sign in predicting the need for hospitalization in young Pakistani infants is given in Table 3.
Table 3
Sensitivity and specificity of individual signs, and the 7-sign algorithm for identification of the sick infant requiring hospital admission, for each age group
| Ages 0–6 days n = 1633 | Ages 7–27 days n = 817 | Ages 28–59 days n = 500 |
Signs | Sensitivity (95% CI) | Specificity (95% CI) | Sensitivity (95% CI) | Specificity (95% CI) | Sensitivity (95% CI) | Specificity (95% CI) |
History of difficult feeding | 26.0 (19.7,33.0) | 97.2 (96.2,98.0) | 24.1 (13.9,37.2) | 96.6 (95.0,97.8) | 15.0 (5.7,29.8) | 93.7 (91.1,95.7) |
Movement only when stimulated | 22.2 (17.5,27.5) | 99.7 (99.4,99.8) | 20.7 (11.2,33.4) | 99.6 (98.8,99.9) | 7.3 (1.5,19.9) | 99.8 (98.8,100.0) |
Temperature < 35.5 | 13.0 (8.5,18.7) | 98.0 (97.1,98.7) | 5.2 (1.1,14.4) | 98.9 (97.9,99.5) | 2.4 (0.1,12.9) | 99.3 (98.1,99.9) |
Temperature ≥ 37.5 | 24.7 (18.6,31.7) | 90.8 (89.2,92.3) | 27.6 (16.7,40.9) | 96.3 (94.6,97.5) | 12.2 (4.1,26.2) | 96.0 (93.8,97.6) |
Respiratory Rate > 60 | 51.4 (43.9,58.8) | 81.6 (79.5,83.5) | 46.6 (33.3,60.1) | 92.1 (89.9,93.9) | 56.1 (39.7,71.5) | 92.2 (89.3,94.4) |
Severe chest indrawing | 12.4 (8.0,18.1) | 99.7 (99.2,99.9) | 24.1 (13.9,37.2) | 100.0 (99.5,100.0) | 39.0 (24.2,55.5) | 97.6 (95.8,98.8) |
History of convulsions | 9.7 (5.9,14.9) | 99.5 (99.0,99.8) | 1.7 (0.0,9.2) | 98.7 (97.6,99.4) | 9.8 (2.7,23.1) | 98.5 (96.9,99.4) |
7-sign algorithm | 85.9 (80.1,90.6) | 71.6 (69.2,74.0) | 72.4 (59.1,83.3) | 83.1 (80.3,85.7) | 80.5 (65.1,91.2) | 80.2 (76.2,83.7) |