Fact Sheet No 178
REDUCING MORTALITY FROM MAJOR KILLERS OF CHILDREN
Each year, more than eleven million children die from the effects of disease and inadequate nutrition. In some countries, more than one in five children die before they reach their fifth birthday, and many of those who do survive are unable to grow and develop to their full potential.
Seven out of 10 of childhood deaths in developing countries can be attributed to just five main causes, or often to a combination of them: pneumonia, diarrhoea, measles, malaria and malnutrition. Around the world, three out of every four children seen by health services are suffering from at least one of these conditions.
While a great deal has been learned from disease-specific control programmes during the past 15 years, the challenge remained how to combine the lessons learned into a single method for more efficient and effective management of childhood illness. WHO, in collaboration with UNICEF, responded by jointly developing an approach called Integrated Management of Childhood Illness (IMCI).
The World Bank's World Development Report 1993 describes the Integrated Management of Childhood Illness 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 are now deemed essential to reaching the goal set by the 1990 World Summit for Children of reducing childhood mortality by 50% by the year 2000.
Integrated Management of Childhood Illness (IMCI)
Children brought for medical treatment in the developing world are often suffering from more than one condition, making a single diagnosis impossible and inappropriate. Such children may need combined therapy for successful treatment. An integrated strategy takes into account the various factors that put children at serious risk. It ensures the combined treatment of major childhood illnesses, it speeds urgent treatment of seriously ill children, it involves parents in the effective care of their children at home whenever possible, and it emphasises prevention of disease through immunization, improved nutrition, and exclusive breastfeeding.
A single diagnosis may be inappropriate for many sick children
Integrated management of childhood illness allows for greater efficiency during 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.
IMCI addresses childhood illness at three levels: it promotes improvements in the health system, improvements in health worker skills, and improvements in family and community practices.
At the heart of the new integrated strategy is the case management of the five most common causes of mortality among children. Standard treatment guidelines have been devised to enable health workers to assess sick children by observing easily recognisable signs. The health worker uses a colour-coded triage system to classify the condition of the child and decide whether it needs urgent referral for more specialized care or medical treatment on the spot, or whether advice on home care given to the parents will suffice. This process does not mean that health workers cease to treat individual diseases. Rather, they must broaden their approach to consider and respond to the condition of the whole child, and to the number of different factors that might be contributing to its sickness.
Pneumonia: correct management could save over 1 million lives per year
Acute respiratory infection (ARI), mostly in the form of pneumonia, 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 may die very quickly from the infection and thus need treatment urgently.
IMCI reduces the death toll from ARI in developing countries by promoting:
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.
Diarrhoea: correct management could save nearly 1.8 million lives per year
Another two million children die each year in developing countries from diarrhoeal diseases, making it the second most serious killer of children under five worldwide. But diarrhoea can in most cases be prevented or treated. Correct management of diarrhoea could save the lives of up to 90% of children who currently die from the effects of the disease.
MCI reduces the death toll from diarrhoea by promoting:
Diarrhoea may be caused by a wide variety of infections but health workers following the IMCI approach learn to make rapid treatment decisions by determining the duration of the diarrhoea, assessing the severity of dehydration and the presence of blood in stools. This leads them to selecting treatment protocols for either: persistent diarrhoea (more than 14 days), acute watery diarrhoea, or dysentery. This approach is both life-saving and cost-effective.
While urgent diagnosis and treatment of diarrhoea may be a priority for saving a child's life, IMCI-trained health workers also consider the child's overall health status. For example, by treating the malnutrition that often accompanies diarrhoea, further risk to the child's health can be reduced. Increasing vigilance to detect other diseases that can occur concurrently with diarrhoea, such as measles or malaria, is also emphasized.
Measles: effective prevention and treatment could save 700 000 lives per year
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 reduces the death toll from measles by promoting:
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. IMCI-trained health workers learn to recognize the complications of measles that they can treat and those that need rapid referral for more specialized treatment.
Malaria: correct management could save 500 000 lives per year
Approximately 700 000 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 reduces the death toll from malaria by:
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.
Malnutrition: improved feeding practices could save 800 000 lives per year
Although malnutrition is rarely listed as the direct cause, it contributes to about 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, giving food in insufficient quantities and without ensuring that the child eats its share - contribute to malnutrition. Malnourished children are, in turn, more vulnerable to disease.
IMCI improves the nutrition of children by:
IMCI-trained health workers check the nutritional status and feeding practices of every child under two years of age, and those with a low weight for their age. They counsel parents on the correct foods for each age group and help them to overcome various feeding problems. They are able to assess a mother breastfeeding her child and to correct any difficulties.
It is between 6 and 24 months, the transition between exclusive breastfeeding and sharing fully in the family diet, that children are most at risk of becoming malnourished. 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 feasible solutions for them to adopt. Relatively simple changes to feeding practices, such as helping toddlers to eat rather than leaving them to fend for themselves, can ensure that a child gets enough to eat during this critical period.
The special importance of breastfeeding: a modest increase in breastfeeding rates could prevent up to 10% of all deaths of children under five:
Breastfeeding plays an essential and sometimes underestimated role in the treatment and prevention of childhood illness. 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, in addition to giving complementary foods, maintains good nutritional status and helps prevent diarrhoea. IMCI promotes breastfeeding by:
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.
Other prevention activities
Prevention is an important part of IMCI and a key to further reduction in the levels of child mortality. An important step forward in the prevention of pneumonia, for example, is likely to be through the use of new vaccines. In recent trials, vaccination provided 100% protection against pneumonia due to Haemophilus influenzae type b, the second most common cause of the disease. An effective vaccine against rotavirus, a major cause of dehydrating diarrhoea, is also available. IMCI-trained health workers use every contact with a child to check and increase vaccination coverage.
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%.
For malaria, the proper use of insecticide-impregnated bednets can reduce child deaths by as much as 30%.
Research and development
WHO ensures that in selecting research priorities, practical needs are paramount. WHO has drawn up a list of future research priorities related to IMCI. While much of this research is concerned with biomedical questions, there is also a need for operational research to address the effectiveness of the treatment guidelines and of interventions for disease prevention, and for further behavioural research on issues such as encouraging parents to seek treatment for their children and adapting advice on feeding to local conditions. The following are a few examples of areas where more information is needed:
Management of severe disease in young infants (under two months of age);
Family and community patterns of care-seeking for sick children.
Improving health systems
In many developing countries, health sector reforms are under way, and WHO strongly encourages the inclusion of IMCI in the early stages of reform planning. Technical support and guidance are also provided in key areas such as improving the availability and supply of essential drugs compatible with IMCI guidelines, more efficient organization of work in health facilities, and improved supervision of health workers.
Improving health worker skills
Training health workers is a key activity in the long-term undertaking to improve their skills in providing care to sick children. The IMCI clinical management course trains health workers in first-level facilities (outpatient clinics and health centres) to effectively manage illness in an integrated fashion in 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 standard case-management guidelines and emphasizes hands-on practice. But course materials are adapted to each country or local situation. This adaptation ensures that the course follows national policies. In the case of appropriate drugs to recommend, it ensures that local disease factors are taken into account, for example adding dengue haemorrhagic fever, or deleting malaria if there is no risk in the area. Finally, the adaptation provides a means of identifying both local foods and drinks for feeding recommendations, and locally accepted terminology to make communication more successful.
Case management at first-level facilities must be complemented by case management at the referral level. WHO is currently developing guidelines and training materials aimed at improving care in small hospitals and to improve the management of those children too sick to be treated at outpatient clinics. WHO is also working on methods to introduce IMCI into the curriculae of training schools for health professionals.
Improving family practices
The importance of a child's social context in determining health cannot be underestimated. Promoting health at home and within the wider community plays an essential part in WHO's integrated approach. Good feeding practices, immunization, improved hygiene and the healthy development of children will all reduce child mortality rates.
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. Systems are also being devised to teach parents what to do if their children do fall ill: where and when to go for appropriate help, and the importance of following treatment advice.
For more information, please contact the WHO Division of Child Health and Development (CHD), Tel (+41 22) 791 2632, Fax (+41 22) 791 4853, Website www.who.ch/chd; or Health Communications and Public Relations, WHO Geneva, Tel (+41 22) 791-2584, Fax (+41 22) 791 4858, E-Mail: email@example.com .
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