Because there is considerable overlap in the signs and symptoms of several of the major childhood diseases, a single diagnosis for a sick child is often inappropriate. Focusing on the most apparent problem may lead to an associated, and potentially life-threatening, condition being overlooked. Treating the child may be complicated too by the need to combine therapy for several conditions.
What are the advantages of this approach?
Integrated management of the sick child leads to more accurate identification of illnesses in outpatient settings, ensures more appropriate and, where possible, combined treatment of all the major illnesses and speeds up referral of severely ill children. Health workers are trained in how to communicate key health messages to mothers, thus helping them understand how best to ensure the health of their children.
This situation argues for child health programmes that address not single diseases but the sick child as a whole. A lot has been learned from disease-specific control programmes in the past 15 years. The challenge is to combine these lessons into a single more efficient and effective approach to managing childhood illness. A number of programmes in WHO and UNICEF have responded to this challenge by developing an approach now referred to as integrated management of the sick child. Already a number of other agencies, institutions and individuals are contributing to this initiative.
Evidence from surveys of health worker performance and of management of illness in the home suggest that, in both these areas, improvements can be made that are likely to reduce mortality significantly. As potentially fatal illnesses in children are often brought to the attention of health workers at first-level health facilities, the initiative for integrated management of the sick child is focusing first on improving their performance through training and support. At the same time work has started on approaches to changing family behaviour in relation to sick children including when and where families seek care outside the home. The approach gives attention to prevention of childhood disease as well as to treatment. It emphasizes the importance of immunization, vitamin A supplementation if necessary, and improved infant feeding, including exclusive breastfeeding.
Integrated management of the sick child means efficiency in training, and in the supervision and management of outpatient health facilities. Wastage of resources is reduced because children are treated with the most cost-effective intervention for their condition. The approach avoids the duplication of effort that may occur in a series of separate disease control programmes.
According to the World Bank's World Development Report 1993, management of the sick child is the intervention likely to have the greatest impact in reducing the global burden of disease. This approach alone is calculated to be able to prevent 14% of that burden in low-income countries. According to the same report, management of the sick child ranks among the most cost-effective health interventions in both low-income and middle-income countries.
Why integrated management of the sick child is a priority?
The health system and the services it delivers should:
What tools are being developed?
Case management guidelines:
Integrated outpatient management of the sick child at the first-level health facility has been described on four wallcharts which will also be available in booklet form. These guidelines are based on experience to date and on the findings of some focused research studies. The charts are titled, respectively:
Assess and classify the sick child age 2 months up to 5 years, treat the child,
counsel the mother, and assess, classify and treat the sick young infant age 1 week up to 2 months.
The guidelines focus on detecting and managing the most common potentially fatal illnesses and associated conditions. They do not attempt to cover all childhood illnesses. The assessment process uses 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).
This procedure classifies each illness according to whether it requires: urgent referral, specific medical treatment and advice, or simple advice on home management. The first step in the process is to look for non-specific danger signs that indicate the child is severely ill and needs urgent referral. Following this, for all children, the health worker asks questions about four main presenting symptoms.
The child presenting with cough or difficult breathing is handled according to the previous WHO/ARI management charts. The illness is classified as "severe pneumonia or other very serious disease" (requiring referral), "pneumonia" or "cough and cold".
A child presenting with diarrhoea is managed according to the already widely used WHO diarrhoea management charts. The child's dehydration status is classified, as are persistent diarrhoea and dysentery if present. Treatment is defined accordingly.
If fever is among the presenting complaints, a classification of "severe febrile illness" indicates that urgent referral is needed. Depending on the other symptoms present and the risk of malaria, this disease may be diagnosed. Fever may also be the starting point for a classification of measles with or without complications.
Mastoiditis and chronic or acute ear infection are the classifications that can be made from the examination of an ear problem. In addition to these classifications based on presenting symptoms, nutritional status is assessed for all children. Severe malnutrition or severe anaemia indicate the need for referral while less severe deficiencies result in treatment and/or advice in the health facility. Each child's immunization status is also checked and vaccinations given as needed. Finally the health worker is reminded to assess and treat any other problems detected.
Management of childhood illness - a training course:
The case management guidelines constitute the technical core of a training course that has been developed for first-level health facility workers. This course consists of a set of six training modules for participants, still-photo exercises, video film and detailed instructions for the course director and course facilitators. It emphasizes hands-on practice of the skills taught.
A pretest of the course in Gondar, Ethiopia, in August 1994, followed by several weeks of observation of the trained health workers, yielded very promising results. A complete field test of the materials is planned for February-March 1995 in Arusha, Tanzania. It is anticipated that the course will be available in mid-1995.
A guide to local adaptation of the training materials is also in preparation. This will include guidance on modification of such things as foods and fluids to be included when counselling the mother, antimicrobials of choice in a particular epidemiological context, and other policy decisions.
On-the-job training in management of drug supplies:
Guidelines for conducting a training workshop followed by supervised practice in the place of work have been developed in collaboration with BASICS to help health workers better manage the drugs essential for management of sick children. They will be field tested in Africa in the second quarter of 1995 and are expected to be ready for use by July 1995.
Other materials under development:
Two other sets of guidelines - on improving health workers' performance and on assessing and changing family behaviours related to care for sick children - are being developed with the help of specialists in these areas. As many sick children require referral to a hospital, a further training course is being developed on inpatient case management of the sick child. Work has also begun on a survey manual for assessing health worker performance, based on those already available for diarrhoea and ARI.
Guidelines for introducing the integrated approach in countries are also being put together.
Research on the management of the sick child:
Research is an essential component of all programmes to reduce mortality and morbidity in children. Several research studies have already been carried out to provide information for finalizing the four sick child case management charts. These include evaluation of the Assess and classify chart in Gambia and Kenya, and studies on the clinical predictors of anaemia in India and Malawi. The studies have led to modification or validation of the following aspects of the protocol: the clinical signs for classifying children as requiring antimalarials in low-risk areas have been refined; the clinical signs for classifying children as having severe anaemia requiring referral have been improved for greater specificity; detection of fever by touch was shown to be sufficiently sensitive and specific to justify the recommendation to "feel the child for fever" if no thermometer is available; visible severe wasting was found to be adequate to detect most children with very low weight-for-height for referral to hospital; the rate of referral and antibiotic use with the revised protocol were found to be acceptable.
A multicentre study on persistent diarrhoea in Bangladesh, India, Mexico, Pakistan, Peru and Viet Nam has provided important findings that have been used to update the recommendations for management of persistent diarrhoea. Findings from a study on pneumonia, sepsis and meningitis in Ethiopia, Gambia, Papua New Guinea and the Philippines have also been used to complete the recommendations for diagnosis and treatment in young infants.
WHO has drawn up a list of future research priorities related to management of the sick child. In addition to improving the detection and treatment of the five major illnesses, areas where more information is needed include: detection and management of anaemia and meningitis; nutritional management; management specific to the sick young infant; reasons why mothers do not seek health care for sick children; identification of high-risk children; adequacy of clinical management in first-level health facilities.
While much research is concerned with biomedical questions, there is also a need for further behavioural research on, for example, communication with mothers, including the adaptation of advice on feeding to local conditions. Research has been carried out by a number of collaborating institutions and coordinated by the WHO Division of Diarrhoeal and Acute Respiratory Disease Control and the WHO Special Programme for Research and Training in Tropical Diseases. In 1993 and 1994 a series of consultations were organized to obtain expert advice on various topics, to review research findings and to redefine research priorities. Two research and development coordination meetings have also been held with participation of a wide range of current or potential collaborators.
Plans for implementation:
The concept of the integrated approach to childhood illness has been welcomed by many countries. In some it will fit well into reorganizations of health service management that are already under way. In others, organizational changes or clearly defined collaborative arrangements between existing disease-specific programmes will be needed. WHO, UNICEF and their collaborative partners will work with countries to
help adapt the new materials to the country context, to plan how implementation of activities can best be managed and to evaluate the experience. Particularly close monitoring of initial experience will be carried out in a small number of countries.
Collaborating partners:
Many institutions are collaborating in this initiative as listed in the attached table.
Bilateral aid agencies from many countries, the World Bank, UNDP and UNICEF are supporting these efforts through their funding of WHO Programmes. Funds specifically designated for this initiative have been provided to WHO by the Governments of Norway and Switzerland and by the US Agency for International Development.
Collaborating institutions:
In addition to the Ministries of Health in countries where activities related to integrated management of the sick child have been carried out, the following institutions have collaborated: World Health Organization; Division of Diarrhoeal and Acute Respiratory Disease Control (CDR); Division of Communicable Diseases (CDS); Division of Control of Tropical Diseases (CTD); Action Programme on Essential Drugs (DAP);
Global Programme for Vaccines (GPV); Maternal and Child Health and Family Planning (MCH); Nutrition (NUT); Oral Health (ORH); Programme for the Prevention of Blindness (PBL); Special Programme for Research and Training in Tropical Diseases (TDR); World Bank, Department of Population, Health and Nutrition;
UNICEF; Child Survival Unit; Bamako Initiative Unit
Other institutions:
Ehtiopia: Addis Ababa University,Gondar Medical College; The Gambia: Medical Research Council; Italy: Istituto "Burlo Garofalo"; Kenya:
Kenya Medical Research Institute, Wellcome Trust; South Africa: The South African Institute for Medical Research, University of Cape Town; Tanzania: Tanzanian Food and Nutrition Unit; UK: Cambridge University, London School of Hygiene and Tropical Medicine, Liverpool School of Tropical Medicine, Medical Research Council, Save the Children Fund, University of Edinburgh; USA: Academy for Educational Development, USAID/SARA, Center for Disease Control and Prevention, Johns Hopkins University, USAID/Child Survival Project, Harvard Institute for International Development, USAID/ADDR, Michigan State University, The Partnershiop for Child Health Care, Inc., USAID/ BASICS, University of Colorado, University Research Corporation, USAID/Quality Assurance Project.
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Last updated January 21, 1999