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All data generated or analysed during this study are included in this published article. The datasets are available from the corresponding author on reasonable request. Infant morbidity and mortality rates remain high in Indonesia, with acute respiratory illnesses ARI and diarrhea the leading two health problems in children under 5 years.
This study was an observational study conducted in parallel to an immunogenicity and efficacy trial of an oral rotavirus vaccine RV3-BB in the Klaten and Yogyakarta regions, Indonesia. Mothers were interviewed at 3 time points: Imuunisasi February and Januarymother-infant pairs were recruited. Adherence to WHO guidelines for management of ARI and imunlsasi was poor, with high use of non-recommended cough medications and oral bronchodilators in the first 6 months of life and low use of ORS and zinc therapy.
Ongoing education of primary health care workers and parents regarding management of common illness is needed in Indonesia. Despite the improvement in the health status of Indonesian infants in the last two decades, mortality rates remain high, estimated at Inthe prevalence of ARI and diarrhea was 0. The IBHS also reported that malnutrition was common, with 6. Importantly, macronutrient deficiencies have been associated with an increased risk of developing ARI and diarrhea, [ 7 ] with a 4-fold increase in ARI-related deaths in severely malnourished children compared to children with normal nutritional status [ iadi9 ].
Identifying effective disease prevention and management strategies in Indonesia remains an important goal to decrease the morbidity and mortality rate from ARI and diarrhea. Furthermore, the routine national immunisation program covers BCG, hepatitis B, polio, DPT, HiB and measles vaccines, with with rotavirus and pneumococcal vaccines currently jadeal to the private sector [ 10 ]. One of challenges of case management in health facilities in developing countries is poor adherence to available guidelines to manage ARI and diarrhea [ 1617 ], resulting in inaccurate assessment of the signs and symptoms which contribute to incorrect diagnosis, inappropriate treatment [ 16 — 18 ] and poor outcomes [ 1920 ].
However, current case management practice, such as the prescription of medications and how the WHO and local pediatric recommendations were followed for ARI and diarrhea in South East Asia, including Indonesia, is not well described.
We hypothesized that [ 1 ] poor nutritional status would be common in infants, [ 2 ] imunizasi of EBF would be high and that [ 3 ] the management of acute ARI and diarrhea would not be consistent with the available guidelines in Indonesia.
We conducted an observational imuniassi, in parallel to a clinical trial of an oral rotavirus vaccine RV3-BB in the Klaten and Yogyakarta regions, Indonesia. Selection of these Primary Health Care Centers was to provide information from rural and semi-urban villages. Both the Klaten and Sleman regions are located in the Java, the most densely populated island in Indonesia.
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The Klaten region is situated in central java, on the border between the central java and Yogyakarta provinces. The region is divided into 26 districts with a population of just over 1. Sleman, is situated in Yogyakarta province and is more urbanized, with a population of 1, people in [ 24 ]. Inthe proportion of famillies living in poverty in Klaten was slightly higher compared to Sleman, The main inclusion criteria for the trial were full term infants in good health with a birth weight between 2.
Once participants were deemed eligible to enter the immunogenicity study, mothers were invited to participate in and provide consent for our study. The study involved two components:. Our study commenced a month after 49 participants had already been recruited in the immunogenicity study.
Of the remaining participants, we invited each mother to provide consent for our study. We approached the remaining trial participants. In total out of mothers in the immunogenicity study of the trial were enrolled in this study.
Separate study specific CRFs were designed to capture the required data at each of the three follow-up assessment time-points in this study through face-to-face interview with the mother. Phone interviews were performed when face-to-face interviews at clinics were not possible and home visits were attempted if parent s were un-contactable by phone.
EBF was defined as infants who were exclusively breast fed at the time of the assessment with no additional food or formula. Strongest support of EBF was defined as who was reported by the mother to provide the strongest support to continue EBF and the option was herself, the father or any relative or friend. Mothers were asked for reasons if they had stopped breastfeeding before the assessment.
Diarrhea was defined as three or more stools in a h period that were looser than normal. The median IQR for maternal age was 29 range: The majority of infants had a normal weight for age and length for age at all three time points. No hospitalization was reported for any episode of diarrhea.
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Results are number percentage. Jadaal study was conducted alongside a rotavirus vaccine clinical trial at three separate time points after birth and has provided valuable insights into breastfeeding practices and the management of both ARI and diarrhea in two regions of Indonesia.
This is substantially lower than national finding in where the proportion of underweight, wasted and stunted infants in Indonesia was As expected, the overall nutritional status of infants within our study was higher than the general population of infants in Indonesia since they had higher engagement with the health system through the clinical trial and improved access to early detection of nutritional problems compared with the general population.
Nevertheless, imjnisasi is clear that nutritional problems are still an issue in Indonesia. To address the national problems in under nutrition, madwal Indonesian government has engaged with the Scaling Up Nutrition SUN movement, a program that aims to provide jadwall specific nutritional intervention for pregnant women and children under 5 years i.
Moreover, a fifth of the total infants participating in this study were at possible risk of overweight and might need further nutritional evaluation. Improvement in the economic conditions in developing countries may increase the prevalence of overweight and obesity that co-exists with under nutrition through factors such as life styles changes such as reducing physical activitiesurbanisation and aggressive nutrition interventions for undernourished children [ 31 ].
In the Indonesian Pediatric society published a guideline for the management and prevention of childhood obesity.
Other recommendations include the introduction of a wide variety of foods, avoidance of sweetened beverages and snacks and no televisions in bedrooms [ 32 ]. The current national Indonesian EBF rate of Other studies have reported that mothers who face difficulties maintaining EBF are more likely to have limited partner support [ 36 ].
Most of the infants were reported to be breastfed for more than 10 times per day as recommended by American Academy of Pediatrics [ 37 ].
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Expectorants, mucolytic agents in cough medication, antihistamines and oral bronchodilators are not recommended medication for the management of URTI in children. In addition, a systematic review reported that most cough medications in children are not effective [ 3839 ] and there have been a number of reports of toxicity and deaths related to cough medications in young infants, [ 4041 ] mostly due to Chlorpheniramin maleat CTM and ambroxol.
In the current study, CTM is the second most commonly prescribed cough medication in infants, especially in primary health care settings. Studies reported that CTM can depress the central nervous system or cause dysrhythmias [ 4142 ]. This was possibly because the dosage of cough and cold medication deemed to be safe in infants had been extrapolated from adult data with limited safety data available for use in young infants [ 40 ]. Education of mothers and health workers regarding the risk and health benefits for giving the abovementioned therapies in infants is required.
WHO guidelines recommend that bronchodilators in ARI are given by inhalation and not by oral therapy [ 21 ] and are only recommended when children present with wheeze with unclear cause or wheeze with the presence of fast breathing or chest indrawing, and not for mild cough. There is little evidence of a beneficial effect from giving oral bronchodilators for the treatment of cough alone [ 21 ]. A randomised controlled trial in India comparing the use of oral salbutamol for symptomatic relief in acute cough with placebo concluded non-superiority of oral salbutamol [ 43 ] and there was also little evidence, that oral salbutamol affected the mean duration of fever, cough, and noisy breathing or the time to the resolution to normal activities compared with placebo.
Of most concern, 5 out of Indian infants in the bronchodilator group were reported to have adverse effects including tremors [ 4344 ]. Salbutamol use in neonates has also been associated with supraventricular tachycardia [ 45 ]. Considering there appears to be limited or no benefit from giving oral salbutamol for the treatment of mild ARI in infants, and there are substantial safety concerns, administration of oral salbutamol is not recommended for infants and further education of health care providers in Indonesia is needed.
The use of ORS and zinc supplementation to treat diarrhea was low in our study. Low implementation of ORS might be due to home solutions being given over ORS due to the ease of availability and for palatability reasons or due to low adherence to WHO guidelines in community settings, once again raising the need for further education of healthcare workers.
There were several limitations to the current study. The general health of infants in this study would be higher than the general population as all the participants were enrolled in a clinical trial, were regularly monitored and had good engagement with the health system. In addition, we did not collect severity of diarrhea within this study, which may have been lower as participants were included in a rotavirus vaccine clinical trial, although both vaccine and placebo participants were included.
Diarrhea severity would also have impacted on the use of ORS and zinc, but regardless use was reported to be very low with poor adherence to guidelines for diarrhea case management. There was also the potential for recall bias with ARI and diarrhea episode management, with episodes retrospectively reported by the mother. Further clarification was sought from medical reports held at the PHCs on treatment but completeness of the diagnostic and management information varied. Our findings highlight the need for ongoing education of community health providers in the support of EBF and optimal case management for childhood ARI and diarrhea in Indonesia.
We thank all the infants and their families for their participation in this study. We also thank all the hospital and community pediatricians, doctors and midwives; the health district office staff who were involved in this study from the initiation, recruitment and follow up, Prof Stephen Michael Graham who had reviewed the manuscript and provided important insights and to all research assistants involved in the study; Rizka Dinari, Meysitha Haris, Asih Sri Utami, Niken Safitri, Dewi Setiani and Septi Kurnia Lestari.
Funding for the study was obtained from the Shepard foundation. Study execution and collecting material: Data analysis and interpretation: All authors read and approved the final manuscript.
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Published online Dec Oktaria1, 2, 3 K. Bines2, 3 E. Watts3 C. Satria1 J.
Atthobariimuniisasi, 4 H. Nirwati1, 5 C. Javwal3, 6 Y. Soenarto1 and M. Author information Article notes Copyright and License information Disclaimer. Received Jan 4; Accepted Dec Associated Data Data Availability Statement All data generated or analysed during this study are included in this published article.
Abstract Background Infant morbidity and mortality rates remain high in Indonesia, with acute respiratory illnesses ARI and diarrhea the leading two health problems in children under 5 years. Methods This study was an observational study conducted in parallel to an immunogenicity and efficacy trial of an oral rotavirus vaccine RV3-BB in the Klaten and Yogyakarta regions, Indonesia.
imunosasi Results Between February and Januarymother-infant pairs were recruited. Nutritional status, Case-management, Indonesian infants, Breastfeeding, Acute respiratory illness. Background Despite the improvement in the health status of Indonesian infants in the last two decades, mortality rates remain high, estimated at