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The Integrated Management of Childhood Illness (IMCI) guidelines developed in the mid-1990s facilitated the management of sick young infants in primary care, especially in developing countries, but they did not cover the first week of life and tended to result in high referral rates, with a risk of health systems being overburdened. Now a study in Bangladesh, Bolivia, Ghana, India, Pakistan, and South Africa (Lancet 2008;371:135–42 see also Comment, ibid: 97–8) has provided more information about clinical signs of illness in children under the age of 2 months brought by their carers to health facilities. The study included 3177 babies aged 0–6 days and 5712 aged 7–59 days. A decision rule based on the presence of any one of 12 symptoms or signs gave 87% sensitivity and 74% specificity for severe illness in the first week of life. After the list of signs was reduced to seven, sensitivity was 85% and specificity 75%. The seven signs were history of difficulty feeding, history of convulsions, movement only when stimulated, respiratory rate ⩾60 breaths/min, severe chest indrawing, temperature ⩾37.5°C, or temperature <35.5°C. Among infants aged 7–59 days the sensitivity was 74% and specificity 79%. The authors of this paper recommend the list of seven for identifying severe illness in infants up to 2 months of age brought to health facilities. …

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