update/lepoint - world health...

Update /Le point

Integrated management of the sick child*World Health Organization, Division of Diarrhoeal and Acute RespiratoryDisease Control1

Diarrhoea, pneumonia, measles, malaria and malnutrition account for more than 70% of deaths andhealth facility visits among children under 5 years of age in developing countries. A number of pro-grammes in WHO and UNICEF have developed an approach to the integrated management of the sickchild, which is being coordinated by WHO's Division for the Control of Diarrhoeal and Acute RespiratoryDisease. Integrated dlinical guidelines have been developed and a training course for health workers inoutpatient (first level) health facilities has been completed. In addition to case management of thesediseases, the course incorporates significant prevention of disease through promotion of breast-feeding,counselling to solve feeding problems, and immunization of sick children. Other materials to train andsupport health workers are also being developed: an inpatient case management training course, medi-cal school curricular materials, a drug supply management course, and materials to support monitoringand reinforcement of skills after training. A planning guide for interventions to improve household man-agement of childhood illness is also being developed. Since management of the sick child is a cost-effective health intervention, which has been estimated to have a large impact on the global burden ofdisease in developing countries, the completion of these materials and their wide implementation shouldhave a substantial impact on child mortality.

Introduction

The need for an integrated approach to sickchildren

Every year some 12 million children die before theyreach their fifth birthday, many of them during thefirst year of life. The majority (70%) of these deathsare due to diarrhoea, pneumonia, measles, malaria ormalnutrition - and often to a combination of theseconditions (Fig. 1). In addition to this substantialmortality, these conditions typically account for threeout of four sick children seeking care at a healthfacility (Fig. 2).

A single diagnosis for a sick child is often inap-propriate because it identifies only the most apparent

* A French translation of this article will appear in a later issueof the Bulletin.1 Requests for reprints should be sent to Division of Diarrhoealand Acute Respiratory Disease Control, World Health Organiza-tion, 1211 Geneva 27, Switzerland.Reprint No. 5653

problem, and can lead to an associated and potential-ly life-threatening condition being overlooked. Treat-ing the child may be complicated by the need tocombine therapies for two or more conditions. Inaddition, the signs and symptoms of several of themajor childhood diseases overlap substantially.Therefore, child health programmes should addressthe sick child as a whole and not single diseases.

Fig. 1. Distribution of 12.2 million deaths among under-5-year-olds in all developing countries, 1993.

ARI 28.9% ARIsbus 5.2%M8sbs 2.4%.. awhoe.+msmsls 1.9%

1.6%228

6.2% ,ePrC2M ofddusaswated wth:At 33.7%Mmlnumittt 29.0%DIarrho 24.7%Mian.t 7.7%

DOwhs _ ^- 9.5%33.1% OneormoreofthmcdWt.ons 71.0%

S. uaepm7 b hnw.*Mom _tWWQ6WOWMGMrAd N .a 1.5

Bulletin of the World Health Organization, 1995, 73 (6): 735-740 © World Health Organization 1995 735

WHO, Division of Diarrhoeal and Acute Respiratory Disease Control

Fig. 2. Percentage frequency of presenting complaintsof 450 children (as given by their mothers), Gondar(Ethiopia), 1994. Based on data from Dr E. Simoes (per-sonal communication).

CoughDiarrhoea

Ear probkrn

Skin leWonsAbdominal painEye discharge

Det problemsNeck swellings

Generalized swellingAnorexia

Rectal prdapseHeadaches

Not recorcied-''---''I 1 I '- I I I

0 10 20 30 40 50 60 70Percentage

Much has been learned from disease-specific controlprogrammes in the past 15 years. The challenge is tocombine these lessons into a single, more efficientand effective approach to managing childhood ill-ness. A number of programmes in WHOa andUNICEFb have responded to this challenge anddeveloped an approach called the integrated manage-ment of the sick child. These efforts are coordinatedby WHO's Division of Diarrhoeal and Acute Respira-tory Disease Control (CDR). Already many otheragencies, institutions and individuals are contributingto this initiative.

a In WHO: Division of Diarrhoeal and Acute Respiratory DiseaseControl (CDR), Division of Communicable Diseases (CDS), Divi-sion of Control of Tropical Diseases (CTD), Action Programmeon Essential Drugs (DAP), Global Programme on AIDS (GPA),Global Programme for Vaccines and Immunization (GPV),Maternal and Child Health and Family Planning (MCH), Nutrition(NUT), Oral Health (ORH), Programme for the Prevention ofBlindness (PBL), and the Special Programme for Research andTraining in Tropical Diseases (TDR).b In UNICEF: Child Survival Unit, Bamako Initiative Unit, andNutrition Unit.

Studies of health workers performance and ofmanagement of illness in the home suggest that, inboth these areas, improvements can be made that arelikely to reduce mortality significantly. As potential-ly fatal illnesses in children are often brought to theattention of health workers at first-level outpatientfacilities, the initial focus of the new initiative is toimprove the performance of these workers throughtraining and support. At the same time approaches tochange the behaviour of families and their responseto sick children, including when and where theyshould seek care outside the home, are being devel-oped.

Developing integrated case managementguidelinesIntegrated guidelines for management of the sickchild have been developed through a process ofreview of existing disease-specific guidelines, re-search, drafting, and field testing. They express, assimply as possible, what needs to be done for sickchildren in order to reduce mortality and preventsignificant disability. Cases are diagnosed withoutlaboratory tests, using simple clinical signs thatstrike a balance between sensitivity and speci-ficity, which health workers from various backgroundscan be trained to recognize accurately. The algo-rithm for the assessment and classification of thechild's illness has been refined through studies in theGambia, Kenya, and Ethiopia, which compared ahealth worker's assessment after training with thatof an expert paediatrician.

The integrated guidelines are presented on fourwall charts, the contents of which are also repro-duced as a booklet.c

Case management processThe case management process, as laid out in thecharts, involves the following steps.* The health worker first assesses the child by ask-ing questions, examining the child, and checking theimmunization status.* Then the health worker classifies the child's ill-nesses, using a colour-coded triage system. Manyhealth workers are already familiar with this throughthe WHO case management guidelines for diarrhoeaand acute respiratory infections (ARI). Each illnessis classified according to whether it requires:- urgent referral;

c Management of childhood illness. Chart booklet. UnpublishedWHO document, 1995 (no number).

736 WHO Bulletin OMS. Vol 73 1995

Integrated management of the sick child

- specific medical treatment and advice; or- simple advice on home management.* After this classification, specific treatments areidentified. If the child is to be referred urgently, thehealth worker gives only essential treatment beforethe patient is transferred. Since most children havemore than one illness, an integrated treatment plan isdeveloped.* Practical treatment instructions are followed,including how to teach the mother to administer oraldrugs, to increase fluid intake during diarrhoea, andto treat local infections at home. The mother is ad-vised on how to recognize the signs which indicatethat the child should immediately be brought to theclinic and is given the dates for routine follow-up.* Feeding is assessed and counselling on feedingproblems provided.* Follow-up instructions for the various conditionsare given when the child returns to the clinic.

Management of childhood illness

A training course for first-level facility healthworkers

A training course in the use of the case managementprocess was developed for first-level facility healthworkers with the ability to read with ease andunderstand the written learning materials. The full11 -day course combines classroom work and hands-on clinical practice built around the integrated casemanagement guidelines. The seven training modulesincorporate photo and video exercices, individualfeedback on exercises, group discussions and drills,and role plays. The mornings are spent in the clinicor hospital with the sick children, the course provi-ding substantial clinical experience in assessment,classification, treatment and counselling over tenclinical sessions. The participants manage the sickchildren under supervision in the outpatient clinicand assess and classify hospitalized children underthe guidance of a skilled clinical instructor. Eachparticipant sees 30-50 sick children.

Communication skills are emphasized in thecourse and are taught from the first day in each mod-ule and during clinical practice, as well as in roleplays in the classroom.

Conditions covered by the course

At the start of the assessment process all the childrenare checked for general danger signs which are notdisease-specific, e.g., a child who is lethargic orunconscious, or is unable to drink or breast-feed, or

vomits everything, or has had convulsions during theillness. These signs may indicate a severe illnessrequiring urgent referral.

In the case of children aged between 2 monthsand 5 years, the health worker then asks about fourmain presenting symptoms: cough or difficult breath-ing, diarrhoea, fever, and ear problems.* The child presenting with cough or difficultbreathing is assessed by the rate of breathing (perminute), looking for chest indrawing and listeningfor stridor. Chest indrawing, stridor when the child iscalm, or one of the general danger signs indicatessevere pneumonia or a very severe disease whichrequires referral. Children with fast breathing aloneare classified as having pneumonia. The absence ofthese signs indicates a simple cough or cold. Chil-dren who have been coughing for more than 30 daysare referred for further investigation of tuberculosisand other conditions. These guidelines are almostidentical with the existing WHO/ARI case manage-ment guidelines.d e* Health workers are taught how to manage acutewatery diarrhoea (including cholera), dysentery(bloody diarrhoea), and persistent diarrhoea (diar-rhoea for 14 days or more). The assessment and clas-sification of dehydration has been simplified, draw-ing on years of clinical experience with the WHOdiarrhoea case management chart. Rehydration thera-py is provided to treat clinically apparent dehydra-tion (fluid Plans B and C in the WHO chart) or toprevent it from developing (fluid Plan A). Dysenteryis treated with an oral antibiotic effective againstShigella. Careful nutritional management is providedfor persistent diarrhoea, and any extra-intestinalinfections which may be contributing to the problemare treated.* Children with fever are evaluated for the presenceof the most common potentially fatal febrile illness-es. A child with fever and a stiff neck or a generaldanger sign may have severe malaria, meningitis orsome other very severe febrile disease. Such childrenare referred urgently to hospital after treatment withan antibiotic and, in malarious areas, quinine. Man-agement of febrile children without these severesigns depends on whether the risk of malaria is highor low. In an area or season with a high malaria risk,all children with fever or a history of fever are treat-ed with the oral first-line antimalarial. If the malaria

d WHO Programme for the Control of Respiratory Infections.Management of the young child with an acute respiratory infec-tion. Unpublished WHO document, revised 1991.e Acute respiratory infections in children. Case management insmall hospitals in developing countries. Unpublished WHO docu-ment, WHO/ARI/90.5, 1990.

WHO Bulletin OMS. Vol 73 1995 737


risk is low, the child is given an antimalarial only ifanother cause for the fever is not apparent. Any childwith a fever every day for more than 7 days is refer-red for investigation of typhoid and other conditions.

Given the overlap in clinical presentation andthe efficacy of co-trimoxazole in the treatment ofboth pneumonia and falciparum malaria,f 9 co-trimoxazole alone is recommended for the treatmentof children who present with cough, fast breathingand fever (in settings where falciparum malaria issensitive to sulfadoxine-pyrimethamine and wherethis recommendation has been incorporated intonational policy).

Fever is also the starting point for a diagnosis ofmeasles. Despite substantial success in improvingimmunization coverage in many developing coun-tries, many measles cases continue to occur. Theircase-fatality rate can be reduced by good manage-ment of the common complications and use of vita-min A.* A history and simple examination can lead todiagnosis of mastoiditis and acute and chronic earinfections. Health workers learn to teach mothershow to wick dry a draining ear and that, while anti-biotics are given for acute ear infection, cases ofmastoiditis should be referred.

All children are assessed for malnutrition andanaemia. Visible severe wasting (marasmus) andoedema of both feet (kwashiorkor) identify childrenwith severe malnutrition who need urgent referral tohospital. A very low weight-for-age identifies agroup of malnourished children whose weight gainshould be monitored in a follow-up visit and whosefeeding needs careful assessment so that any prob-lems can be remedied.

Severe palmar pallor is present in a high propor-tion of children with severe anaemia who requirereferral to hospital for transfusion; others requiringtransfusion present with cough or difficult breathingand are referred with the classification of severepneumonia or very severe disease.h Children withsome palmar pallor are treated with oral iron for twomonths.

A similar process - assess, classify, identifytreatment, treat, and counsel - is taught for themanagement of the sick young infant (age 1 week upto 2 months) as for the sick child (age 2 months upto 5 years). Because the signs of pneumonia and

f The overlap in the clinical presentation and treatment of malar-ia and pneumonia in children: report of a meeting. UnpublishedWHO document WHO/ARI/92.23, 1992.9 Antimalarial drug policies: data requirements, treatment ofuncomplicated malaria and management of malaria in pregnan-cy. Unpublished WHO document WHO/MAU94.1070, 1994.hSee footnote d on page 737.

other serious bacterial infections cannot easily bedistinguished, every young infant is assessed for aset of signs and, if any one sign is present, they areclassified as having a possible serious bacterial infec-tion. These infants are referred urgently after initialtreatment, which includes antibiotics and breast milkor sugar water to prevent low blood sugar.

Preventive interventions covered in thecourse

In addition to case management of the most impor-tant diseases, the course includes prevention ofdisease through the promotion of breast-feeding,advice on solving feeding problems, and improvedimmunization coverage by ensuring the immuniza-tion of sick children. Encounters with sick childrenprovide an opportunity for the delivery of sound,consistent advice on the nutrition of the young childboth during and after illness, which may have asignificant impact in reducing the adverse effect ofinfections on nutritional status.

A feeding assessment is carried out for childrenwho are less than 2 years of age or are very lowweight-for-age, and their feeding is compared withage-specific feeding recommendations. Local adapta-tion of these recommendations and identification ofcommon feeding problems are an important step inadapting the course to each country. To try toachieve an impact on child nutrition, the nutritioncounselling focuses on remediable feeding prob-lems, rather than providing general nutritional ad-vice. Children with a feeding problem are followedup to provide further help in resolving feedingproblems and to check on their weight gain.

Exclusive breast-feeding is encouraged for thefirst 4-6 months and guidance is provided to solveimportant problems; use of bottle-feeding is discou-raged at any age. A young infant with difficulty inbreast-feeding, or who is low weight-for-age, or is notbreast-feeding often enough or exclusively is observedduring feeding. This assessment determines whetherthe infant's attachment on the breast is good andwhether suckling is effective. If these are not satisfac-tory, the health worker is trained to help the mother toimprove the infant's position and attachment.

Each child's immunization status is checked andvaccinations are given as needed. The importance ofimmunizing sick children who are not referred tohospital is taught repeatedly and reinforced, so thatthere will be fewer missed opportunities for immu-nization.

In countries where vitamin A deficiency is aproblem, sick child encounters can be used as anopportunity to provide periodic vitamin A supple-mentation.


Integrated management of the sick child

Field testing of the training course

A preliminary test of the course in Gondar, Ethiopia,in August 1994, followed by three weeks of observa-tion of the performance of the trained nurses, yieldedvery promising results. A full field test, includingmaterials for course instructors, was carried out inArusha, Tanzania, in March 1995. All three types ofhealth workers included in the field test were able tolearn and apply the process of assessment, classifica-tion, treatment, and counselling at a very acceptablelevel of performance.

Both these tests demonstrated the effectivenessof the course for inservice training of clinical nursesand medical assistants. In the field test, health work-ers with little previous training (in Tanzania, ruralmedical aides and MCH aides) were also able tolearn the case management process and performedwell in the clinic; however, because they had diffi-culty in reading the modules in English, they re-quired more active facilitation and were not able tocomplete the course in the time available. A revised,simplified course was translated into the locallanguage and is now being tested to determine its ef-fectiveness in training other fully literate primaryhealth care workers with less basic training. WHO is

also exploring how the course might be used duringpre-service training for nurses and health assistants.

The course requires adaptation to situations incountries, taking account of different disease epi-demiology and country-specific policies and guide-lines. An adaptation guide is being prepared toreview clinical policy and guidelines, to identify thenecessary adaptations of the course, and then toadapt the present charts and clinical modules. For theidentification of appropriate feeding recommenda-tions and local feeding problems, a protocol is avail-able to guide a review of existing information and tocarry out a household trial of feeding recommenda-tions. After adaptation, the course should be translat-ed to the language of the country.

Potential impact and cost-effectivenessAccording to the World Bank's report for 1993 (1),management of the sick child is the interventionwhich is likely to have the greatest impact in re-ducing the global burden of disease. This approachalone is calculated to be able to prevent 14% of thatburden in low-income countries. According to thereport, management of the sick child ranks amongthe most cost-effective health interventions in bothlow-income and middle-income countries (Fig. 3).

Fig. 3. Cost-effective packages of public health Interventions and essential clinical services In low-income andmiddle-income countries.

Management of the sick child

Immunization (EPI Plus)

Prenatal and delivery care

Family planning

AIDS prevention programnme

Treatment of STDs

Short-course chemfotherapy for tuberculosis

School health programme 10.1%

Tobacco and alcohol programme

40.00

14.50

40.00

25S00

4.00

2.00

4.00

22.50

42.50

I I I I I I I I I0 2 4 6 8 10 12 14 16 AnnualcoSt

Percentage of total global disease burden averted per DALY

US$

1.60

0.50

3.80

0.90

1.70

0.20

0.60

0.30

0.30

I

Annual costper capita

Source: World development report. investing in health, 1993 (1).

WHO Bulletin OMS. Vol 73 1995

F

14%

6%

.4%m

3%

M

739


Future plansThe case management training course describedabove is only one component of an integratedapproach to the management of the sick child. Othermaterials for training and support to health workersare described briefly below.- As many sick children require referral to a hospi-

tal, a further training course is being developedon inpatient case management of the sick child.

- Medical school curricular materials including amanual for students on individual disease topicsand their integration are being developed. Thiswill expand on the materials already producedfor diarrhoeal disease.'

- To improve the management of drug supplies athealth facilities, which is essential for effectivecase management, materials for conducting atraining workshop followed by supervised prac-tice in the health facility have been developed incollaboration with the USAID-funded BASICS(Basic Support to Institutionalizing Child Survi-val) Project.

- To maintain good performance in the manage-ment of sick children, training in monitoring andskill reinforcement will be provided to all healthworkers who have completed the course on man-agement of childhood illness. Further training onsubjects not fully covered in the course will beimplemented through health facility visits, dis-tance learning materials, and refresher trainingsessions in district hospitals.

- A planning guide is being developed in responseto the need for interventions to improve house-hold management of childhood illness, including

References on diarrhoea. Strengthening the teaching of diar-rhoeal diseases in medical schools. Unpublished WHO docu-ment, 1993 (no number).

timely care-seeking. The guide provides asystematic process for assessing current problemsin household management, identifying culturallyappropriate interventions, and implementing andevaluating them.In addition, WHO (Division of Diarrhoeal and

Acute Respiratory Disease Control) has drawn up alist of research priorities related to integrated man-agement of the sick child and will support an activeresearch programme focused on these priorities.Research relevant to malaria case management with-in integrated management of the sick child is sup-ported by the Applied Field Research Task Force onthe Sick Child, WHO Special Programme forResearch and Training in Tropical Diseases (TDR).

The concept of the integrated approach to child-hood illness has been welcomed by many countries.In some it will fit well into reorganizations of healthservice management that are already under way. Inothers, organizational changes or clearly defined col-laborative arrangements between existing disease-specific programmes will be needed.

WHO, UNICEF, the World Bank and their col-laborative partners will work with countries to helpadapt the new materials to the country context, toplan how implementation of activities can best bemanaged, and to evaluate the experience. Particularlyclose monitoring of initial experience will be carriedout in a small number of countries. In order to facili-tate further progress in this important new initiativeand to ensure maximum collaboration from otheragencies and institutions, WHO will continue to holdperiodic meetings to coordinate research, develop-ment and implementation activities.

Reference1. The World Bank. World development report 1993:

investing in health. New York, Oxford UniversityPress, 1993.


update/lepoint - world health...

Documents