Seven out of 10 childhood deaths in developing countries can be attributed
to just five main causes, or a combination of them: pneumonia, diarrhoea,
measles, malaria and malnutrition. Around the world, three out of every
four children who seek healthcare are suffering from at least one of these
conditions. Many of these deaths can, however, be prevented by better health
management: WHO recommends the Integrated Management of Childhood Illness
The Integrated Management of Childhood Illnesses (IMCI)
It is apparent that sick children's signs and symptoms may overlap. Recognizing, consequently, which condition is present can be difficult and a single diagnosis is often inappropriate. Treatment of the sick child may also be complicated by the need to combine therapies for several conditions. The situation calls for child health programmes which address the sick child as a whole.
Integrated management has several key advantages. It leads to more accurate diagnoses in outpatient settings; ensures more appropriate and, where possible, combined treatment of major illnesses; and speeds referral of severely ill children. The approach gives due attention both to treatment of childhood disease as well as to prevention, emphasizing immunization, Vitamin A supplementation if needed, and improved infant feeding, including exclusive breastfeeding.
Integrated management of the sick child allows for greater efficiency
in training and in the supervision and management of outpatient health
facilities. It reduces wastage of resources such as intravenous fluids
and antibiotics by treating sick children with the most cost-effective
intervention for their condition. The approach also avoids the duplication
of effort that may occur in a series of separate disease control programmes.
The problem: Acute respiratory infection (ARI) is the leading cause of death in children under five, killing over two million children annually. Up to 40% of children seen in health clinics are suffering from ARI and many deaths attributed to other causes are, in fact, "hidden" ARI deaths.
In most cases, pneumonia can be effectively treated with low-cost oral antibiotics. The problem is that children die very quickly from the infection and need treatment urgently.
IMCI solution: Health workers following the IMCI approach learn the
importance of classifying the severity of respiratory infections by observing
the child for two key signs of pneumonia - chest indrawing and fast breathing.
They are also aware that children suffering from other conditions, such
as malnutrition or measles, are particularly susceptible to pneumonia,
and thus they are on the lookout for the early signs of the disease to
ensure rapid treatment.
The problem: Over 2 million children die each year in developing countries from diarrhoeal diseases. The illness can be caused by a wide variety of infections, in particular due to the consumption of contaminated food and water.
IMCI solution: IMCI emphasizes determining the duration of the diarrhoea, assessing the severity of dehydration and the presence of blood in the stools in order to categorize the type of diarrhoea and propose appropriate treatment.
The three main types of diarrhoea:
|Type of diarrhoea||% of cases of diarrhoea||% of deaths due to diarrhoea||% of deaths preventable by standard case management|
Health workers are trained to recognize the three main types of diarrhoea:
The problem: Despite the major impact made on this disease by successful immunization programmes, measles infects over 40 million children and kills over 800,000 under-fives each year. That translates to 2,000 deaths of young children every day from measles, often in association with diarrhoea and pneumonia.
IMCI solution: Young children with measles often develop acute respiratory
infections, diarrhoea and malnutrition, and children who survive measles
are more vulnerable to other dangerous infections for several months afterwards.
Trained health workers learn to recognize the complications of measles
that they can treat and those that need rapid referral for more specialized
The problem: Nearly 600,000 children die of malaria each year, most of them in sub-Saharan Africa. Young children are particularly vulnerable because they have not developed the partial immunity that results from surviving repeated infections.
Malaria is a widespread tropical disease caused by a parasite transmitted to humans by mosquitoes. It has proved difficult to control because mosquitoes have become resistant to insecticides used against them and because the parasite has developed resistance in some areas to the cheap and effective drugs that used to provide good protection. However, alternative drug therapies have been developed for use in areas of resistance.
IMCI solution: Children with malaria can in most cases be quickly and
effectively treated with a course of inexpensive oral tablets. But because
fever may be the only sign of malaria, it may be difficult to distinguish
it from other potentially life-threatening conditions. IMCI enables health
workers to make more accurate assessments of children with fever, providing
them with the treatment they need and avoiding excessive use of drugs.
The problem: Although malnutrition is rarely listed as the direct cause, it contributes to more than half of all childhood deaths. Lack of access to food is not the only cause of malnutrition. Poor feeding practices and infection, or a combination of the two, are both major factors.
Infection, particularly frequent or persistent diarrhoea, pneumonia, measles and malaria, undermines nutritional status. Poor feeding practices - inadequate breastfeeding, offering the wrong foods in insufficient quantities and without ensuring that the child eats his/her share - contribute to malnutrition. Malnourished children are, in turn, more vulnerable to disease.
IMCI solution: IMCI-trained health workers check the nutritional
status and feeding practices of every child they see. They counsel parents
on the correct foods for each age-group and help them overcome various
feeding problems. They are able to assess a mother breastfeeding her child
and to correct any problems.
Improving family practices
An important element of IMCI is the encouragement of a healthier home life. Good feeding practices, immunization, improved hygiene and the healthy development of children will all reduce child mortality rates. Achievement of better living conditions begins with the parents.
Through IMCI, health workers counsel parents on how to improve care for their sick children. Workers teach them how to administer drugs to combat pneumonia, how to follow the three rules of home care for diarrhoea - increase fluids, continue feeding and recognize the danger signs that mean their child needs further treatment in a health facility - how to care for children afflicted by measles and how to protect their children from malaria by using insecticide-impregnated bednets.
Many children die because their parents do not recognize danger signs indicating that they might be suffering from one of the above conditions or any other illness. IMCI-trained health workers work with parents to ensure they recognize the signals and get their sick children promptly to a person capable of giving specialized care.
Changing family habits and the kinds of food offered to children is
an important element of IMCI. An effective way of doing this is through
talking to mothers individually about home care and their child's feeding
difficulties, and finding solutions that would be feasible for them to
adopt. Where appropriate, IMCI-trained health workers advise on the best
ways of ensuring young children get the nourishment they need for healthy
growth and development. Quite simple changes can make all the difference.
Helping a toddler to eat, for example, rather than leaving him/her to serve
him/herself from the family dish, can greatly increase the amount of food
he/she actually consumes.
The special importance of breastfeeding
Breastfeeding plays an essential and sometimes underestimated role in the treatment and prevention of childhood illness. As many as 10% of all deaths of children under five could be prevented by a modest increase in breastfeeding rates worldwide. For this reason, promotion and support of breastfeeding is a key feature of IMCI.
When mothers breastfeed exclusively during at least the first four months and, if possible, six months of life, there is a dramatic decrease in episodes of diarrhoea and, to a lesser extent, respiratory infections. Even small amounts of water-based drinks decrease breastmilk intake and weight gain, and increase the risk of diarrhoea. Continuing to breastfeed up to two years of age, besides giving complementary foods, maintains good nutritional status and helps prevent diarrhoea.
There is, however, evidence that the duration of breastfeeding worldwide is decreasing. In Zambia, for example, there has been a steady increase in bottle feeding since the 1970s. During the period 1977-1992, the infant mortality rate has increased by 35%.
Mothers often give their babies other food and fluids before six months because they doubt their breastmilk supply is adequate and they do not know how to improve the situation. IMCI recommends one-on-one counselling with mothers on breastfeeding techniques and benefits. WHO has developed courses in breastfeeding counselling for healthcare providers. Moreover, whenever a sick young child is taken to a clinic or health facility, the IMCI-trained health worker enquires about and assesses breastfeeding and provides the help and support needed to solve most common difficulties, while referring more serious problems to specialists.
WHO's tips for feeding your child
Breastfeed your child. Give only breastmilk up to at least the age of 4 months and, if possible, up to 6 months.
Giving only breastmilk (no other foods or fluids, even water) helps to protect your child against sickness. Most mothers have enough breastmilk. By feeding your child frequently and for longer periods, you can increase the amount of breastmilk.
When your child is 6 months old, begin to offer other foods.
Thick cereal, meat, fish, eggs, beans, fruits and vegetables will give your child energy and will help your child to grow.
Continue to breastfeed up to the age of two years - as often as your
Even when you give other foods, breastfeeding will help to protect your child against sickness.
Feed your child actively.
Sit with and encourage your child to eat. Put your child's serving in a separate plate or bowl to ensure that he or she has an adequate share of the family food.
If your child is sick:
- Breastfeed more often.
- If your child has started eating other foods, offer food more often, in small amounts, and give plenty to drink.
Other prevention activities
Prevention is an important part of IMCI and a key to further reduction in the levels of child mortality. Vaccination, for example, is a major means of prevention. IMCI-trained health workers use every contact with a child to check and increase vaccination and immunization coverage.
In recent trials in the Gambia, vaccination provided 100% protection against pneumonia due to Haemophilus influenzae type b, the second most common cause of the disease. Other vaccines, against the very common pneumococcus infection, are also being tested.
The best protection against measles is also immunization. In addition, Vitamin A supplements have been found to reduce the severity of both measles and diarrhoea: trials in developing countries have shown that Vitamin A supplements can reduce death from these and other infectious diseases by almost 25%.
Use of insecticide-impregnated bednets can reduce deaths from malaria
and trials in several countries have shown an overall reduction in childhood
death rates of 35%.