Fact Sheet N96
INTEGRATED MANAGEMENT OF THE SICK CHILD
While a great deal has been learned from disease-specific control programmes during the past 15 years, the challenge remained of how to combine the lessons learned into a single method for more efficient and effective management of childhood illness. WHO and UNICEF responded by jointly developing an approach referred to as integrated management of the sick child.
According to the World Bank's World Development Report 1993, integrated management of the sick child is seen as the intervention likely to have the greatest impact in reducing the global burden of disease. It is also among the most cost-effective health interventions in low- and middle-income countries. Indeed, adoption and implementation of this approach is now deemed essential to reaching the goal set in the 1990 World Summit for Children of reducing childhood mortality by 50% by the year 2000.
Why An Integrated Approach?
Every year some 12 million children die before reaching their fifth birthday, many of them during their first year of life. Of these, 70% are killed by one of five causes -- diarrhoea, pneumonia, measles, malaria or malnutrition -- and often by some combination of them (chart, page 4). Around the world, three of every four children who seek health care are suffering from at least one of these conditions.
Because their signs and symptoms may overlap, recognizing which of these conditions is present in a sick child 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 argues for child health programmes which address the sick child as a whole, not just single diseases.
Integrated management presents 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 prevention of childhood disease as well as to treatment, 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.
Standard Treatment Guidelines
Newly developed treatment guidelines for the sick child cover the most common potentially fatal conditions. The health worker assesses every child for non-specific danger signs; for the four main symptoms of cough or difficult breathing, diarrhoea, fever and ear problems; for nutritional status; and for immunization status.
CASE MANAGEMENT PROCESS
1. The health worker assesses the child -- asking questions, examining the child and checking immunization status.
2. The health worker then classifies the illness based on a colour-coded triage system, with which many health workers are already familiar through use of the WHO case management guidelines for diarrhoea and acute respiratory infections (ARI). The system classifies illnesses according to whether they require a) urgent referral, b) specific medical treatment and advice, or c) simple advice on home management.
3. After classifying the illness, the health worker identifies specific treatments. If the child is being urgently referred, the health worker gives only urgent treatments beforehand.
4. The health worker then provides practical instructions, such as how to administer oral drugs, increase fluids during diarrhoea and treat local infections at home. Mothers are advised on the signs which indicate the child should immediately be brought back to the clinic and when to return for follow-up.
5. For children under 2 years of age and those who are malnourished, the health worker assesses feeding, notes any feeding problems, and provides counselling on feeding problems.
Training health workers is a key activity in the long-term undertaking to improve the system for providing care to sick children. The WHO/UNICEF course Management of Childhood Illness trains health workers in first-level facilities (outpatient clinics and health centres), enabling them to effectively manage illnesses in an integrated fashion in sick children between the ages of 1 week and 5 years. The course also teaches them to communicate key health messages to mothers, helping them to understand how best to ensure the health of their children.
The training course is based on the treatment guidelines and emphasizes hands-on practice. But course materials must be adapted to local situations so that, for example, local foods and drinks can be mentioned or locally appropriate drugs recommended.
Research is an essential component of all programmes to reduce mortality and morbidity in children. WHO has drawn up a list of future research priorities related to integrated management of the sick child in order to improve the detection and treatment of the five major illnesses. Examples of areas where more information is needed:
While much research is concerned with biomedical questions, there is also a need for further behavioural research on issues such as communicating with mothers and adaptation of advice on feeding to local conditions.
For more information, please contact Office of the Spokesperson, WHO, Geneva, Tel (4122) 791-2599 or 791-4858 (fax).