The Key Word Is Integrated
A holistic approach to the management of childhood illness can save thousands of lives each year
A sick child is more difficult to treat than an adult. Not only that, children, because of their underdeveloped immune system, are more susceptible to infections and diseases that put their lives at risk.
Children below five years old are most at risk. The World Health Organization notes that the number of deaths among children in this age group has dropped by almost one third in the last 30 years. But the reduction has not been evenly distributed.
The WHO says children in more than 50 low- to middle-income countries are 10 times more likely to die before reaching five than those in developed countries. These countries have child mortality rates of more than 100 per 1,000 live births. In these countries, poverty, ignorance, and lack of access to health care conspire to every year deny more than 10 million children of the chance to celebrate fifth birthday. Nearly 70 percent of them die because of pneumonia, diarrhea, measles, malaria, or malnutrition.
And even in areas where health care is available, the WHO notes that "many sick children are not properly assessed and treated, and that their parents are poorly advised." The WHO cites several reasons for this inequity.
Diagnostic facilities are mostly lacking. Irregular flow of patients leaves doctors at this level with few opportunities to practice complicated clinical procedures. As a result, the WHO says, doctors "often rely on history and signs and symptoms to determine a course of treatment that makes the best use of available resources."
But the WHO also notes that improving health care for children does not always require sophisticated and expensive technologies. "Effective strategies based on a holistic approach, and which take into account the existing capacity and infrastructure," can do much to improve basic health care, says the WHO.
That's why the WHO is promoting the concept of integrated management of childhood illness (IMCI). "Children health programs need to move beyond addressing single diseases to addressing the overall health and well-being of the child," it says.
The WHO notes that individually, many health intervention programs-immunization, oral rehydration for diarrhea, promotion of breast-feeding-have contributed much to reduction of infant deaths. But it argues that an integrated approach to managing sick children is needed "because many children present with overlapping signs and symptoms of diseases [that] a single diagnosis can be difficult, and may not be feasible or appropriate."
Gimme Five
IMCI targets children under five years old because they are the ones most at risk of dying from common childhood diseases.
According to the WHO, the IMCI guidelines take an "evidence-based, syndromic approach to case management that supports the rational, effective, and affordable use of drugs and diagnostic tools." The approach is used to determine:
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health problems the child may have,
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severity of the child's condition,
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actions that can be taken to care for the child.
It also promotes:
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adjustment of the curative interventions to the capacity and functions of the health system, and
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active involvement of family members and the community in the health care process.
It addresses the knowledge gap through counseling of parents so that they can do more to promote the health of their children by adopting correct health practices, heeding the advice of health care providers, and bringing their children to a doctor as soon as they see symptoms of a possible sickness.
IMCI addresses both preventive and curative interventions at all levels of the health care system-including the home. Its guidelines are based on the following principles:
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All sick children must be examined for general danger signs, which indicate the need for immediate referral or admission to a hospital.
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All sick children must be routinely assessed for major symptoms. They must also be routinely assessed for nutritional and immunization status, feeding and other potential problems.
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Only a limited number of carefully selected clinical signs are used based on evidence of their sensitivity and specificity to detect disease.
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A combination of individual signs leads to a child's classification rather than diagnosis. Classification indicates the severity of condition. They call for specific actions based on whether the child should be urgently referred to another level of care, be given specific treatment, or may be safely managed at home.
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The IMCI guidelines address most but not all of the major reasons a sick child is brought to a clinic. A child returning with chronic problems or less common illnesses may require special care. The guidelines do not describe the management of trauma or other acute emergencies due to accidents or injuries.
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IMCI management procedures use a limited number of essential drugs and encourage active participation of caretakers in the treatment of children.
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An essential component of the IMCI guidelines is the counseling of caretakers about home management, including counseling about feeding, fluids, and when to return to a health facility.
The WHO encourages member-countries to adapt these guidelines to their conditions and needs, taking into account the most serious diseases normally seen at first-level health facilities and prevailing national treatment guidelines and policies.
Under the set-up the management of a sick child brought to a first-level health facility involves three modes of action.
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At the outpatient health facility for assessment, classification and identification of treatment; referral, treatment, or counseling of the caretaker; and follow-up care.
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At a referral health facility for emergency triage assessment and treatment or further diagnosis, treatment or monitoring of the patient's progress.
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At home for appropriate management. In this regard, the parent or caretaker is taught how to give oral drugs and treat infections at home, feed the sick child, or administer fluids, and monitor the progress of treatment.
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