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Background

THE SICK CHILD INITIATIVE

In the early 1990s, bilateral donors, especially the European contingent, reiterated the need to develop an integrated approach to the management of childhood illness. The rationale for an integrated approach included the following:

  • It was recognized that children often were treated for one symptom. Because there is considerable overlap in signs and symptoms of several of the major diseases, a single diagnosis focusing on the most apparent problem may lead to an associated condition being overlooked.

  • With separate disease-specific guidelines and training, the health worker was left the difficult task of integration during his or her encounter with the sick child.

  • Young infants with life-threatening illnesses often presented with nonspecific clinical signs, which made a disease-specific approach difficult.

  • Many national governments were moving toward policies of integrated disease management without any clear guidelines on how to achieve this.

Consequently, in 1992 the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) initiated development of an integrated approach to managing the main life-threatening diseases of childhood —pneumonia, diarrhea, malaria, measles, and malnutrition—which together cause approximately three-quarters of deaths in children under 5 years of age. The Sick Child Initiative (SCI), as this approach has come to be known, builds on



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Consideration of the Nutrition Components of the Sick Child Initiative 1 ◆ ◆ ◆ ◆ ◆ Background THE SICK CHILD INITIATIVE In the early 1990s, bilateral donors, especially the European contingent, reiterated the need to develop an integrated approach to the management of childhood illness. The rationale for an integrated approach included the following: It was recognized that children often were treated for one symptom. Because there is considerable overlap in signs and symptoms of several of the major diseases, a single diagnosis focusing on the most apparent problem may lead to an associated condition being overlooked. With separate disease-specific guidelines and training, the health worker was left the difficult task of integration during his or her encounter with the sick child. Young infants with life-threatening illnesses often presented with nonspecific clinical signs, which made a disease-specific approach difficult. Many national governments were moving toward policies of integrated disease management without any clear guidelines on how to achieve this. Consequently, in 1992 the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) initiated development of an integrated approach to managing the main life-threatening diseases of childhood —pneumonia, diarrhea, malaria, measles, and malnutrition—which together cause approximately three-quarters of deaths in children under 5 years of age. The Sick Child Initiative (SCI), as this approach has come to be known, builds on

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Consideration of the Nutrition Components of the Sick Child Initiative more than 16 years of experience with case management of diarrheal diseases, primarily by oral rehydration therapy, and more than 7 years of research on, and program management of, acute respiratory infections (ARI). The major purpose of the SCI is to train primary health care providers to diagnose diseases and prescribe the appropriate treatment at the health center level, or to refer cases with complications immediately to a district hospital. As such, the SCI is not intended to be the main program or substitute for existing preventive and community health and nutrition activities. Research and development activities of the SCI, coordinated at WHO by the Division of Diarrhoeal and Acute Respiratory Disease Control (CDR), are called the Integrated Management of Child Illness (IMCI). A number of other institutions and individuals—including, for example, UNICEF, USAID, and the U.S. Centers for Disease Control and Prevention (CDC)—are collaborating in these activities. According to the SCI, the sick child is assessed initially through a limited range of questions and observation of easily recognized symptoms. The child's nutritional and immunization status are recorded, and immunization is given if needed. The child's condition is classified according to disease grouping and severity guidelines, which are used as a basis for treatment and possible referral to a hospital or other higher-level care if the illness or condition is of sufficient severity. The final step is to give the mother advice on follow-up care. Support for an integrated approach to the management of childhood illness was given further impetus by the estimation of the World Development Report 1993: Investing in Health (World Bank, 1993, p. 77), that the SCI could potentially prevent up to half of deaths in low-income countries, because there is a high fatality rate from common childhood diseases among malnourished children (Pelletier et al., 1993). In addition, the World Development Report 1993 considered integrated management of childhood illnesses to be one of the most cost-effective health interventions and recommended that SCI be given a high priority in countries with child mortality rates of more than 30 deaths per 1,000 children under the age of 5 (World Bank, 1993, p. 114). CHARGE TO THE COMMITTEE The charge from USAID was as follows: Drawing on the scientific and technical knowledge of individual members, background information and other pertinent data, the Committee is requested to make recommendations as to: (1) practicality of the nutrition components of the (SCI) algorithm; (2) whether the nutrition components of the algorithm should or should not be modified, and if to be modified, how; and (3) the additional information or data required to improve the performance of the integrated management of childhood illness algorithm's nutritional effectiveness [see Appendix A].

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Consideration of the Nutrition Components of the Sick Child Initiative During the committee meeting, a request was made that two additional questions be considered: (4) how can nutritional components be monitored during field testing or introductions, and (5) what should the role be for those with experience and expertise in nutrition as field testing or introduction evolves? PROJECT SCOPE It became evident during both the preparation for and evolution of the 2-day meeting of the CIN in January 1995 that the SCI is rapidly evolving. The specifics of the nutrition components are still under development and will benefit from the next phase of the SCI, which will include adaptation of the algorithms for use in specific locations. It was therefore inappropriate for the committee to produce a summative evaluation of the nutrition components as if the SCI were a finished product. Thus, the committee undertook this task as a formative evaluation, commenting on the nutrition components of the SCI with the knowledge that they continue to evolve. It is also important to note that WHO had neither requested advice nor was provided with an opportunity in advance to share information on their progress and deliberations on the SCI. Because the committee did not have access to the latest drafts of WHO documents or to WHO 's current thinking on the SCI, its formative evaluation could not address what WHO is doing or intends to do in the future with respect to further development of the SCI. However, because the committee believes that the SCI is one of the most important enterprises in primary health care in developing countries, it appreciated the opportunity to discuss certain principles that may offer useful guidance to those concerned with its development. As a result, rather than focusing solely on its responses to the specific questions posed by USAID, the CIN has also addressed larger contextual concerns related to the nutrition components of the SCI. Based on the expertise and experience of individual members, the committee has provided detailed comments and suggestions about selected nutrition components, while others are discussed in a more general fashion. Because the committee did not have the background information or time to make comprehensive commentaries on all the nutrition components of the algorithms, it has chosen to present its discussion of selected, specific components as an appendix to the report. Integrating nutrition into the treatment of the sick child is a relatively new venture, and one that deserves the strongest praise. It was apparent to the committee, however, that there has been substantial variation in efforts thus far to validate and test the components of the algorithms relating to nutrition. The long-term involvement of the team developing the SCI with the case

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Consideration of the Nutrition Components of the Sick Child Initiative management of childhood diarrhea and acute respiratory infection may explain, in part, why the components of the algorithms that deal with these illnesses have received more attention and field testing than those relating to nutrition. The committee hopes that its comments will help WHO and other organizations as they move to address this imbalance in further development of the SCI.