AN EVALUATION OF CLINICAL INDICATORS FOR SEVERE PEDIATRIC ILLNESS

To help reduce paediatric morbidity and mortality in the developing wo rld, WHO has developed a diagnostic and treatment algorithm that targe ts the principal causes of death in children, which include acute resp iratory infection, malaria, measles, diarrhoeal disease, and malnutrit ion. With this algorithm, known as the Sick Child Charts, severely ill children are rapidly identified, through the presence of any one of 1 3 signs indicative of severe illness, and referred for more intensive health care. These signs are the inability to drink, abnormal mental s tatus (abnormally sleepy), convulsions, wasting, oedema, chest wall re traction, strider, abnormal skin turgor, repealed vomiting stiff neck, tender swelling behind the ear, pallor of the conjunctiva, and cornea l ulceration. The usefulness of these signs, both in current clinical practice and within the optimized context of the Sick Child Chart algo rithm in a rural district of western Kenya, was evaluated. We found th at 27% of children seen in outpatient clinics had one or more of these signs and that pallor and chest wall retraction were the signs most l ikely to be associated with hospital admission (odds ratio (OR) = 8.6 and 5.3, respectively). Presentation with any of these signs led to a 3.2 times increased likelihood of admission, although 54% of hospitali zed children had no such signs and 21% of children sent home from the outpatient clinic had at least one sign. Among inpatients, 58% of all children and 89% of children who died had been admitted with a sign. A bnormal mental status was the sign most highly associated with death ( OR = 59.6), followed by poor skin turgor (OR = 5.6), pallor (OR = 4.3) , repeated vomiting (OR = 3.6), chest wall retraction (OR = 2.7), and oedema (OR = 2.4). Overall, the mortality risk associated with having al least one sign was 6.5 times higher than that for children without any sign. While these signs are useful in identifying a subset of chil dren at high risk of death, their validation in other settings is need ed. The training and supervision of health workers to identify severel y ill children should continue to be given high priority because of th e benefits, such as reduction of childhood mortality.