Forward

Since the 1970s, the estimated annual number of deaths among children less than 5 years old has decreased by almost a third. This reduction, however, has been very uneven. And in some countries rates of childhood mortality are increasing. In 1998, more than 50 countries still had childhood mortality rates of over 100 per 1000 live births.¹ Altogether more than 10 million children die each year in developing countries before they reach their fifth birthday. Seven in ten of these deaths are due to acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria, or malnutrition - and often to a combination of these conditions (figure 1).

¹ World Health Organization. World health report 1999: Making a difference. Geneva: WHO, 1999.

Projections based on the 1996 analysis The global burden of disease indicate that these conditions will continue to be major contributors to child deaths in the year 2020 unless significantly greater efforts are made to control them.² Every day, millions of parents take children with potentially fatal illnesses to first-level health facilities such as clinics, health centres and outpatient departments of hospitals. In some countries, three in four episodes of childhood illness are caused by one of these five conditions. And most sick children present with signs and symptoms related to more than one. This overlap means that a single diagnosis may not be possible or appropriate, and that treatment may be complicated by the need to combine therapy for several conditions. Surveys of the management of sick children at these facilities reveal that many are not properly assessed and treated and that their parents are poorly advised.³

² Murray CJL and Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases injures, and risk factors in 1990 and projected to 2020. Geneva, World Health Organization, 1996.

³ World Health Organization. Report of the Division of Child Health and Development 1996-1997. Geneva: WHO, 1998.

At this level, in most developing countries, diagnostic supports such as radiology and laboratory services are minimal or non-existent; and drugs and equipment are scarce. Limited supplies and equipment, combined with an irregular flow of patients, leave health care providers at first-level facilities with few opportunities to practise complicated clinical procedures. Instead, they must often rely on history and signs and symptoms to determine a course of management that makes the best use of available resources.

FIGURE 1: DISTRIBUTION OF 11.6 MILLION DEATHS AMONG CHILDREN LESS THAN 5 YEARS OLD IN ALL DEVELOPING COUNTRIES, 1995

*Approximately 70% of all childhood deaths are associated with one or more of these 5 conditions.

Based on data taken from The Global Burden of Disease 1996, edited by Murray CJL and Lopez AD, and Epidemiological evidence for a potentiating effect of malnutrition on child mortality, Pelletier DL, Frongillo EA and Habicht JP, American Journal of Public Health 1993; 83:1139-1133.

Providing quality care to sick children in these conditions is a serious challenge. In response to this challenge, WHO and UNICEF developed a strategy known as Integrated Management of Childhood Illness (IMCI). Although the major stimulus for IMCI came from the needs of curative care, the strategy combines improved management of childhood illness with aspects of nutrition, immunisation, and other important disease prevention and health promotion elements. The objectives are to reduce deaths and the frequency and severity of illness and disability and to contribute to improved growth and development.

The strategy includes three main components:

· Improvements in the case-management skills of health staff through the provision of locally adapted guidelines on IMCI and through activities to promote their use

· Improvements in the health system required for effective management of childhood illness

· Improvements in family and community practices

The core of the IMCI strategy is integrated case management of the most common childhood problems, with a focus on the most important causes of death. The generic guidelines, however, are not designed for immediate use. A guided process of adaptation ensures that the guidelines, and the learning materials that go with them, reflect the epidemiology within a country and are tailored to fit the needs, resources and capacity of a country’s health system.

The clinical guidelines, which are based on expert clinical opinion and research results, are designed for the management of sick children aged 1 week up to 5 years. They promote evidence-based assessment and management, using a syndromic approach that supports the rational, effective and affordable use of drugs. They include methods for assessing signs that indicate severe disease; assessing a child’s nutrition, immunization, and feeding; teaching parents how to care for a child at home; counselling parents to solve feeding problems; and advising parents about when to return to a health facility. The guidelines also include recommendations for checking the parents’ understanding of the advice given and for showing them how to administer the first dose of treatment.

When assessing a sick child, a combination of individual signs leads to one or more classifications, rather than to a diagnosis. IMCI classifications are action oriented and allow a health care provider to determine if a child should be urgently referred to another health facility, if the child can be treated at the first-level facility (e.g. with oral antibiotic, antimalarial, ORS, etc.), or if the child can be safely managed at home.

When used correctly, the approach described in this handbook ensures the thorough assessment of common serious conditions, nutrition and immunization; promotes rapid and affordable interventions; strengthens the counselling of caretakers and the provision of preventive services; and assists health care providers to support and follow national guidelines.