Major Causes of Death in Children Under 5 Years of Age

• Despite the substantial reduction in the number of deaths observed in recent decades, around 10.6 million children die every year before reaching their fifth birthday. Almost all of these deaths occur in low-income and middle-income countries.
• Most deaths among children under five years are still attributable to just a handful of conditions and are avoidable through existing interventions.
• Just a very few conditions account for 70% to over 90% of all these deaths. These are: lower respiratory infections, mostly pneumonia; diarrhea; malaria; measles: HIV/AIDS, and neonatal conditions, mainly pre-term birth, birth asphyxia, and infections. 
• Malnutrition increases the risk of dying from these diseases. Over half of all child deaths occur in children who are underweight.
• The relative importance of the various causes of death has changed, with the decline in mortality from diarrhoea and many of the vaccine-preventable diseases. The relative contribution of HIV/AIDS to the total mortality of children under 5 years of age, especially in sub-Saharan Africa, has been increasing steadily. In 1990 it accounted for around 2% of mortality in the African region among children under 5 years of age, but in 2003 the figure had reached about 6.5%.

Summarizing data across regions and countries masks substantial differences in the distribution of causes of deaths.

• Approximately 90% of all malaria and HIV/AIDS deaths in children, more than 50% of measles deaths and about 40% of pneumonia and diarrhea deaths are in the African region.
• In contrast, deaths from injuries and non-communicable diseases other than congenital anomalies account for 20-30% of deaths among children under 5 years of age in the region of Americas, and in the European and Western Pacific regions.

Steps in Integrated Case Management

The IMCI integrated case management process consists of a number of steps that should be taken by a health-care provider to ensure effective case management.

STEP 1. ASESS

When a child or young infant is brought to a clinic, a health-care provider uses good communication skills to ask the mother about the child's problems and makes an assessment of the child's condition. The health worker checks first for general danger signs, which would indicate any life-threatening condition. In young infant the health worker checks for signs of very severe disease and local bacterial infection. Then the health worker asks specific questions about the most common conditions affecting a child's health. If the answers are positive, he or she examines the child appropriately. An essential part of the assessment is checking the child's nutrition and immunization status. The assessment includes checking the child for other health problems.

STEP 2. CLASSIFY

Based on the results of the assessment a health-care provider classifies a child's illnesses using a specially developed color-coded triage system. Because many children have more than one condition, each condition is classified according to whether it requires:

STEP 3. IDENTIFY TREATMENT

After classifying all the conditions present, a health-care provider identifies specific treatments for the sick child or the sick young infant.

• If a child requires urgent referral (pink classification), essential treatment to be given before referral is identified.
• If a child needs  specific treatment  (yellow classification), a treatment plan is developed, and the drugs to be administered at the clinic are identified. The content of the advice to be given to the mother is decided on.
• If no serious conditions have been found (green classification), the mother should be correctly advised on the appropriate actions to be taken for care of the child at home.

STEP 4. TREAT

After identifying appropriate treatment, a health-care provider carries out the necessary procedures relevant to the child's conditions. The health worker:

• gives pre-referral treatment for sick children being referred;
• gives the first dose of relevant drugs to the children who are in need of specific treatment, and teaches the mother how to give oral drugs, how to feed and give fluids during illness, and how to treat local infections at home;
• provides advice on the home management of sick children at home;
• if needed, asks the mother or other caregiver to return with the child for follow-up on a specific date.

STEP 5. COUNSEL

If the follow-up care is indicated the health-care provider teaches the mother when to return to the clinic, the health worker also teaches the mother how to recognize signs indicating that the child should be brought back to the clinic immediately.

When indicated, a health-care provider assesses feeding, including breastfeeding practice, and provides counseling to solve any feeding problems found. This also includes counseling the mother about her own health.

STEP 6. FOLLOW-UP

Some children need to be seen more than once for a current episode of illness. The IMCI case management process helps to identify those children who require additional follow-up visits. When such children are brought back to the clinic, a health-care provider gives appropriate follow-up care, as indicated in IMCI guidelines, and if necessary, reassess the child for any new problems.

Principles of the Integrated Clinical Case Management Guidelines

The IMCI clinical guidelines are based on the following principles:

• All sick children aged up to five years of age are examined for general danger signs and all young infants are examined for signs of very severe disease. These signs indicate the need for immediate referral or admission to hospital.
• The children and infants are then assessed for main symptoms.  For older children the main symptoms include cough or difficulty breathing, diarrhea, fever, and ear infection. For young infants, the main symptoms include local bacterial infection, diarrhea, and jaundice. In addition, all sick children are routinely assessed for nutritional and immunization status, and other potential problems.
• Only a limited number of clinical signs are used, selected on the basis of their sensitivity and specificity to detect disease.
• A combination of individual signs leads to a child's classification within one or more symptom groups rather than a diagnosis. The classification of illness is based on a color-coded triage system: "pink" indicates urgent hospital referral or admission, "yellow" indicates initiation of specific outpatient treatment, and "green" indicates supportive home care.
• IMCI management procedures use a limited number of essential drugs and encourage active participation of caregivers in the treatment of children.
• An essential component of IMCI is the counseling of caregivers regarding home care, appropriate feeding and fluids, and when to return to the clinic - immediately or for follow-up.

IMCI Benefits

The IMCI strategy:

addresses major child health problems – The strategy systematically addresses the most important causes of childhood death and illness.

responds to demand – Every day millions of parents take their sick children to hospitals and health centers, pharmacists and community health care providers. Three out of four of these children are suffering from at least one of the five conditions that are the focus of IMCI.

promotes prevention as well as cure – In addition to its focus on treatment, IMCI also provides the opportunity for, and emphasizes, important preventive interventions such as immunization and improved infant and child nutrition, including breastfeeding.

Is cost-effective – the World Bank ranked IMCI among the ten most cost-effective interventions in low- and middle-income countries.

promotes cost saving – Inappropriate management of childhood illness wastes scarce resources. Although increased investment will be needed initially for training and reorganization, the IMCI strategy will result in cost savings.

improves equity - Nearly all children in the developed world have ready access to simple and affordable preventive and curative care, which protects them from death as a result of acute respiratory infections, diarrhea, measles, malaria and malnutrition. Millions of children in the developing world, however, do not have access to this same life-saving care. The IMCI strategy addresses this inequity in global health care.

Integrated Case Management as the Core IMCI Intervention

The core IMCI intervention is integrated case management of the most important causes of childhood death and illness, such as acute respiratory infections,diarrhea, measles, malaria, malnutrition, neonatal infections and a few others. The strategy of IMCI includes a range of other preventive and curative interventions, which aim to improve practice both in health facilities and at home.

The WHO/UNICEF case management guidelines are a generic version. Although they are widely applicable, they need to be adapted in a specific country to:

• cover the most serious childhood illnesses seen at first level-health facilities, that first level-health workers must be able to treat;
• be consistent with national treatment guidelines and other policies; 
• be appropriate for the local conditions that affect the care of children in the health facility and at home.

IMCI Objectives, Components and Interventions

The IMCI strategy combines the improved management of childhood illness with aspects of nutrition, immunization and other important factors influencing child health, including maternal health.

The key objectives of the IMCI strategy are to:

• reduce death and the frequency and severity of illness and disability
• contribute to improved growth and development.

The IMCI strategy seeks to reduce childhood mortality and morbidity by adopting a broad and cross-cutting approach with the following three components:

• improving the case management skills of health workers through the provision of clinical guidelines on the integrated management of childhood illness, adapted to the local context, and training to promote their use; 
• Improving the health system by:
• ensuring the availability of essential drugs and other supplies
• improving the organization of work at the health facility level 
• improving monitoring and supervision;
• improving family and community practice through the education of mothers, fathers, other caregivers and members of the community, with a focus on health-seeking behavior, compliance, care at home and overall health promotion.

Each component includes a set of specific interventions, with emphasis on their practical implementation.

The main interventions of the global IMCI strategy evolve to take account of that become available from analysis of the global burden of childhood disease and from child health research.

Rationale for an Integrated Approach

Every year almost 10 million children die before they reach their fifth birthday. A majority of these deaths caused by just five preventable and treatable conditions:

• pneumonia
• diarrhea
• malaria
• measles
• malnutrition

Often, those deaths are caused by a combination of the above conditions. Many of childhood deaths could be avoided if those children received appropriate and timely care. In addition, three out of four episodes of childhood illness are caused by these five conditions.

In the 1990s, major progress was made to reduce childhood mortality and morbidity through universal childhood immunization, control of diarrheal diseases and acute respiratory infections, nutrition programs (including the promotion of breastfeeding) and through implementation of other primary health care activities. In 1995, the WHO Department of Child and Adolescent Health and Development (CAH), in collaboration with eleven other WHO programs and UNICEF, finalized the development of the Integrated Management of Childhood Illness (IMCI) strategy. The global implementation of the IMCI strategy applied the lessons learned from these vertical programs to strategies that promote coordination and, where appropriate, greater integration of activities, in order to improve the prevention and management of childhood illness.

The current challenge for the IMCI strategy is to scale up activities to ensure the appropriate and effective use of IMCI principles and clinical guidelines by all types of health-care providers.

The extent of childhood morbidity and mortality in low-income and middle-income countries caused by the above-mentioned five conditions is not in itself the only rationale for an integrated approach to the management of childhood illness. Every day, millions of parents seek health care for sick children, taking them to hospitals, health centers, pharmacists, community health-care providers and traditional healers, and most of these sick children present with signs and symptoms related to more than one disease.

This overlap means that often a single diagnosis may not be possible or appropriate, and treatment may be complicated by the need to combine therapy for several conditions. An integrated approach to managing sick children is, therefore, indicated. There is a real need for a health care provider to go beyond single diseases and address the overall health of a child. Use of IMCI strategy, which takes into account the variety of factors that put children at serious risk, ensures the combined treatment of the major childhood illnesses, while emphasizing prevention of disease through immunization and improved nutrition.

What is IMCI?

Integrated Management of Childhood Illness (IMCI) is a strategy for reducing the mortality and morbidity associated with the major causes of childhood illness. 

WHO and UNICEF started to develop the IMCI strategy in 1992, and today more than 100 countries worldwide have adopted it. The implementation of the IMCI strategy produces impressive results, both in the decrease of childhood mortality and in improving the quality of life of young children all over the world.

IMCI is an integrated approach to child health that focuses on the well-being of the whole child. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age. IMCI includes both preventive and curative elements that are implemented by families and communities, as well as by health facilities.

The IMCI strategy focuses on:

• improving case management skills of health-care providers
• improving overall health systems
• improving family and community health practices.

The IMCI strategy promotes the accurate identification of childhood illnesses, ensures appropriate integrated treatment of all major illnesses, strengthens the counseling of caregivers, and identifies the need of and speeds up the referral of severely ill children. In the home setting, it promotes appropriate care-seeking behaviors, improved nutrition and preventative care, and the correct implementation of prescribed care.

The cornerstone of the IMCI strategy is a set of evidence-based clinical guidelines. These guidelines have been designed to provide first-level health workers with simple and effective tools to combat the major causes of childhood mortality and morbidity.

According to the World Bank (1993), this approach to the management of common childhood infections and malnutrition is, compared with other interventions, likely to have the greatest impact on reducing the global burden of disease. It is estimated that the IMCI approach alone could potentially prevent 14% of the burden of disease in low-income countries and that it is among the most cost-effective health interventions in both low-income and middle-income countries.