Download in Word format
The WHO Division of Child Health and Development (CHD) supports research with a focus on the development and evaluation of new or improved methods for preventing and managing childhood illness. CHD has identified five priority areas for research:
Case management of childhood illness
Current CHD research priorities focus on the developing clinical tools and guidelines for the management of acute respiratory infections (ARI), diarrhoea, dysentery, measles, meningitis, malaria, and malnutrition. Box A lists specific examples of research questions related to improved case management. Methods for improving the case management of sick young infants are also being investigated. Specific research topics include:
Acute Respiratory Infections
Several research priorities have been identified for improving the efficiency and effectiveness of ARI case management. These include improving the specificity of the diagnosis of non-severe pneumonia in order to limit unnecessary antibiotic use, alternative antibiotic regimes for the management of severe pneumonia, the appropriateness of fluid restriction in severe pneumonia, antimicrobial resistance among organisms responsible for pneumonia, and the management of wheezing and of otitis media.
Severely malnourished children commonly have electrolyte imbalances, with low total body potassium and high total body sodium. Because of this imbalance, standard WHO oral rehydration solution (ORS) may not be appropriate for managing diarrhoea in these children. Investigating the efficacy and safety of an alternative WHO ORS formula, developed specifically for severely malnourished children, has been identified as a research priority.
The increasing resistance of shigella strains of various serotypes to commonly used antibiotics calls for the rapid examination of alternative antibiotic treatments for managing shigellosis.
Many clinicians in developing countries routinely prescribe antibiotics for children with acute measles on the assumption that this will prevent or treat associated bacterial infections. Yet this practice may make the situation worse by promoting the growth of yeasts and unusual organisms. Research is, therefore, required to investigate the role of antibiotics in the management of acute measles.
The practice of fluid restriction in meningitis, which is customary in many places, has recently been questioned, as has the use of adjunctive steroid therapy in developing countries, where mortality is high, patients are younger, and therapy often imperfect. For these reasons the research priorities related to the management of bacterial meningitis are to examine the appropriateness of fluid restriction in infants, and of steroid therapy as an adjunctive treatment in developing countries.
Strengthening the case management of malaria in children requires concentrated research in several different areas. Current priorities are to investigate the reliability of clinical signs to predict malaria in low-risk areas, the management of cerebral malaria, the management of malaria-associated anaemia, and the effectiveness of various treatment options for malaria.
While experts tend to agree that severely malnourished children should receive broad spectrum antimicrobial treatment, there is still no clear scientific evidence to demonstrate the benefits of this. Severely malnourished children also require special feeding regimens, because they are not able to tolerate the usual amounts of dietary protein, fat and sodium. Research is therefore needed to assess the impact of metronidazole treatment, and to examine the efficacy and safety of the two recommended feeding formulas (F75 and F100) in severely malnourished children.
Case Management of Sick Young Infants
Simple signs have been identified to help first-level health workers to identify sick young infants but it is not clear whether these signs can be effectively used to improve neonatal survival in developing countries. Investigating the impact of simple guidelines used by first-level health workers on neonatal survival is therefore a research priority.
Box A lists specific examples of research questions under
the topic of improved case-management.
1. What is the efficacy and safety of alternative antibiotics in the management of bloody diarrhoea due to Shigella?
2. Is oral amoxycillin superior to injectable penicillin for the treatment of severe pneumonia? Can shorter courses of amoxycillin be used to treat outpatient pneumonia?
3. Is fluid restriction appropriate in severe pneumonia?
4. At community level, what factors are responsible for the development and spread of antimicrobial resistance?
5. Which children with wheeze should receive antibiotics?
6. What is the most appropriate fluid regimen for children with severe malaria?
7. Can clinical signs be used to reliably predict malaria in low risk settings?
8. What patient characteristics can help select the severely malnourished children who can be treated from the beginning with the F100 (100kcal/100ml) diet?s some specific research questions under the topic of improved case management.
IMCI implementation at first-level facilities
Implementation of the Integrated Management of Childhood Illness (IMCI) strategy began in 1996. By the end of that year, three countries (Tanzania, Uganda and Zambia) had commenced the training of health workers, and at least 18 additional countries had started planning for IMCI and adapting the case management guidelines for first-level facilities.
Small-scale field research designed to identify, define and address problems with implementation (operational research) is now needed to inform continued IMCI planning and implementation.
In selecting priority questions three factors were taken into account:
Box B lists some of the principal questions for operational research.
1. 1. How do the IMCI guidelines for first-level facilities perform when used by health workers in various developing country settings?
2. How can IMCI training be organized and scheduled in order to optimize its effectiveness?
3. What difficulties do health workers face after IMCI training? How do training follow-up and IMCI job aids affect their performance?
4. What factors are associated with whether or not patients return for follow-up care? What are the outcomes associated with return or no return?
5. What proportion of referred children arrive at referral-level facilities? What are the determinants of successful referral?
6. What is the cost of providing IMCI at a first-level facility for a given population?
Family and community behaviours related to IMCI
Research on family and community behaviours aims to develop interventions to promote the prevention and improved management of childhood illness in the home. Priority areas are investigating interventions related to careseeking, compliance with health worker advice, and to infant and child feeding. Specific research topics include:
Common constraints to careseeking for children include late recognition of health problems which require care outside of the home, and factors preventing use of health care services once a need has been recognized. Priorities for research include identifiying signs and symptoms of illness that can be recognized by caretakers, and investigation of methods to improve caretaker recognition of serious illness signs and to promote timely and appropriate family action.
Counselling mothers is an integral part of the IMCI case management process. Studies are needed to assess compliance with the advice and treatment recommendations provided by first-level health workers trained in IMCI. Research results will be used to improve counselling and to develop interventions promoting behaviour change at household level.
Infant and Child Feeding
Malnutrition is associated with over 50 per cent of childhood deaths. In many settings inadequate feeding practices have been identified as a major contributor to malnutrition. Given that most severely malnourished children are not hospitalized, developing household approaches to prevent and manage severe malnutrition is a priority. Research will include examining how health facility-based and community-based interventions can promote feasible and sustainable improvements in feeding practices.
Box C describes some specific research questions related to family
and community behaviours.
1. How can recognition of serious illness signs be improved, particularly for young infants?
2. What is the most adequate, but simple, set of serious illness signs/symptoms that caretakers can be taught to recognize?
3. In the management of persistent diarrhoea, does the promotion of alternative forms of micronutrient supplements improve compliance?
4. After counselling from IMCI-trained health workers, do mothers understand what they have been advised to do? Do they follow this advice? What factors are associated with compliance?
5. What is the relative efficacy and safety of a simplified home treatment for severe malnutrition when compared with the standard hospital treatment?
6. Which community-based interventions for the promotion of improved feeding practices can achieve effective and sustainable results?
The IMCI strategy emphasizes preventive as well as curative interventions. CHD is therefore supporting the investigation of methods for preventing major childhood illnesses. Current research priorities include testing the effectiveness of vaccines and micronutrient supplementation, and examining the effects of reducing indoor air pollution.
Zinc and vitamin A supplementation have been identified as potentially effective interventions for reducing childhood morbidity and mortality in areas where diets are deficient in these micronutrients. However, information on the effectiveness and safety of zinc and vitamin A supplementation in infants and young children is limited. Priority has been given to examining the effects of zinc supplementation on the incidence and severity of pneumonia in infants, and to investigating the safety and benefits of vitamin A supplementation delivered to young children during immunization contacts.
Indoor Air Pollution
High levels of indoor air pollution have been associated with increased risk of respiratory morbidity and mortality. It has been suggested that decreased levels of indoor air pollution could reduce childhood deaths from pneumonia by more than 10 per cent but studies are needed to confirm such potential benefits.
Vaccines against pneumococcus and Haemophilus influenzae type b are likely to become important tools in the prevention of morbidity and mortality associated with ARI. Studies to examine the efficacy and effectiveness of these vaccines have been identified as a priority.
Box D lists some research questions related to preventive interventions
2. Is it safe and beneficial to deliver Vitamin A in conjunction with early immunizations?
3. Does a reduction in indoor air pollution lead to reduced pneumonia
Impact of the IMCI
It will be important to investigate the impact of IMCI on childhood morbidity and mortality, through research in a limited number of countries. Specific studies are needed to assess whether the implementation of IMCI at first-level facilities is associated with reductions in child mortality and morbidity, both overall and, if possible, from specific diseases.