Causes of death and associated evidence-based interventions
Vaccines
Vaccines are the single most powerful tool for reducing under-five mortality. Key vaccines for preventing premature child death include measles, polio, diphtheria, tetanus, & pertussis (DTP3), Haemophilius influenzae type B, pneumococcal vaccines, and rotavirus. All of these can be administered efficiently and effectively through community health programs.
Community-based prevention and management of common child illnesses
Community health workers and community health posts have helped extend the reach of the public health system to rural and vulnerable communities.
Community health workers have led public education activities to improve health through prevention. Their efforts have improved immunization and breastfeeding rates, promoted use of prevention tools such as ITNs for malaria, and improved hygiene and health-seeking behavior in general to reduce child death.
In many geographies, community health workers also provide diagnostic and treatment services. They can effectively diagnose and treat some of the biggest killers of children under five, including lower respiratory infections, diarrheal diseases, and malaria. Community health workers have also been leveraged to administer antibiotics, oral rehydration therapy, zinc supplements, and antimalarial combination therapy.
Additionally, in an increasing number of countries, community health workers have helped with the long-term management and treatment of HIV and tuberculosis. This includes the prevention of mother-to-child transmission and the testing of children born to HIV-positive mothers.1
Integrated management of childhood illness
Integrated management of childhood illness (IMCI), developed by the WHO and UNICEF, is an integrated approach to child health that focuses on the well-being of the whole child. 2
The strategy, which has already been adopted by more than 100 countries, includes three main components:
- Improving case management skills of health care staff
- Improving overall health systems
- Improving family and community health practices 2
At the heart of the IMCI strategy is an emphasis on prevention through immunization and improved nutrition, combined with the integrated management of five leading causes of childhood deaths: acute respiratory infections, diarrheal diseases, measles, malaria, and malnutrition.
Nutrition education and management of malnutrition
One of the most effective tools for preventing early child death is the promotion of breastfeeding. Exclusive breastfeeding for six months not only improves a child’s nutrition, but also shields the child from unclean local water which might be used to wash and cook household foods.
Community Health Workers and facility-based health professionals have been effective educators and promoters of exclusive breastfeeding and proper complementary feeding for infants over six months old. They have also promoted Vitamin A supplementation, which has been proven to reduce risk of illness and death due to common causes such as measles and diarrhea. Lastly, they have also conducted screening for severe acute malnutrition and have helped manage it, through providing ready-to-use food, rehydration, and antibiotics. 3, 4
Nutrition education and promotion, including breastfeeding and proper complementary feeding, is also a key part of the IMCI strategy.
What Works?
Table 1: Infant and Child Under-5 Mortality Evidence Based Interventions
|
Lower respiratory infections |
Diarrheal diseases |
Malaria |
|---|---|---|
|
Antibiotic treatment
Vaccination: PCV
Vaccination: Hib
Community-based management
Facility-based management |
Oral rehydration therapy
Zinc supplementation
Vaccination: Rotavirus
Community-based management
Facility-based management |
Antimalarial combination therapy
Rapid diagnostic testing
Insecticide-treated nets
Indoor residual spray
Intermittent preventative therapy for high-risk groups
Community-based management
Facility-based management |
|
Measles |
Malnutrition |
HIV |
|
Vaccination: Measles
Vitamin A supplementation |
Exclusive breastfeeding for 6 months
Continued breastfeeding and complementary feeding after 6 months
Vitamin A supplementation
Management of severe acute malnutrition (ready-to-use food, rehydration, antibiotics)
|
Early diagnosis and antiretroviral treatment for infants and children
HIV testing of children born to HIV+ mothers
Prevention of mother-to-child transmission |
|
Meningitis |
Other vaccine preventable diseases |
|
|
Vaccination: PCV meningococcal
Vaccination: Hib
Vaccination: Meningococcal
Vaccination: BCG
Antibiotic treatment
Chemoprophylaxis during acute outbreaks |
Vaccination: Tetanus
Vaccination: Diphtheria
Vaccination: Pertussis
Vaccination: Polio |
. |
Neonatal care
Although about one in ten neonatal deaths are the result of congenital abnormalities, there are still opportunities to reduce neonatal deaths through providing care at the following stages.
Antenatal
Key interventions in the antenatal period can have a large impact on neonatal mortality. All pregnant women should have at least four antenatal visits with a trained provider, including an early visit in the first trimester. (WHO recommendations have recently increased to eight visits). These visits are an opportunity to prevent or diagnose and treat preeclampsia and eclampsia. They are also an opportunity to provide pregnant women with supplements, such as folic acid and iron, which help improve the health of the fetus and test pregnant women for HIV to prevent mother-to-child transmission. Pregnant women should also be given two tetanus vaccinations before their third trimester. In malaria-endemic areas, antenatal visits are an opportunity to ensure pregnant women are provided appropriate prevention interventions, such as insecticide-treated bed nets. Lastly, antenatal care visits can encourage women to deliver at health facilities and can provide health education on subjects such as nutrition and how to identify warning signs of pregnancy complications.
Intrapartum
Facility-based delivery should be encouraged and made available to all expectant mothers. Facilities should follow clean delivery practices, including handwashing, clean cord-cutting, and cord care. In addition, they should provide active management of delivery, including partograph use and provision of postpartum oxytocin. In settings where access to facilities is limited, communities rely on trained skilled birth attendants who can provide basic emergency obstetric and newborn care (BEmONC). However, it is critical to link these skilled birth attendants to referral and transport systems, to ensure access to higher level care when complications arise. This includes access to comprehensive emergency obstetric and newborn care (CEmONC) in higher-level facilities, which can provide the necessary care for mothers.
During delivery, quality care can greatly reduce the risk of early newborn and maternal harm. For example, antibiotics for preterm premature rupture of the membranes (PPROM), corticosteroids for preterm labor, and caesarean-section for breech or obstructed labor can reduce both neonatal and maternal mortality.
Postnatal
Facility providers should be trained and equipped to perform newborn resuscitation, prevent and manage hypothermia, and provide Kangaroo care for low birth weight and prematurity. In addition, they should encourage mothers to begin breastfeeding their newborn within the first hour of life and should keep mothers and newborns in the facility for at least 24 hours after birth.
Early postnatal visits to identify danger signs and provide active referral should be standard practice. Antibiotics can be given to newborns for suspected or confirmed infection, and neonatal intensive care units (with trained staff following established protocols) can safeguard newborns during this riskiest period of their lives.
What Works?
Table 2: Neonatal Mortality Evidence-Based Interventions
|
Preconception |
Antenatal |
|---|---|
|
Folic acid supplementation |
Tetanus vaccination
Malaria prevention and treatment: Intermittent presumptive treatment ITNs
Iodine supplementation (in endemic iodine deficient settings)
4 or more antenatal visits (ANC4)
Prevention and treatment of preeclampsia and eclampsia
|
|
Intrapartum |
Postnatal |
|
Antibiotics for PPROM
Corticosteroids for preterm labor
C-section for breech or obstructed labor
Active management of delivery (including partograph)
Clean delivery practices (incl. clean cord-cutting)
Trained birth attendant
Facility-based delivery
Basic emergency obstetric and newborn care (BEmONC)
Comprehensive emergency obstetric and newborn care (CEmONC)
Timely transport for higher level care for mother |
Newborn resuscitation
Immediate breastfeeding
Prevention and management of hypothermia: Immediate drying and wrapping Delayed bathing Skin-to-skin Baby warming
Kangaroo care for LBW/prematurity
Timely transport for higher level care for mother
Post-partum visits to identify danger signs and provide active referral
Antibiotics for suspected or confirmed infection
Surfactant therapy for RDS and prematurity
Neonatal intensive care units (equipped, trained staff, standards and protocols established and followed) |
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1
Schmitz K, Basera TJ, Egbujie B, Mistri P, Naidoo N, Mapanga W, et al. Impact of lay health worker programmes on the health outcomes of mother-child pairs of HIV exposed children in Africa: A scoping review. PLoS ONE. 2019;14(1): e0211439. https://doi.org/10.1371/journal.pone.0211439. Accessed January 21, 2020.
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2
Integrated Management of Childhood Illness (IMCI). WHO. https://www.who.int/maternal_child_adolescent/topics/child/imci/en/. Accessed January 7, 2020.
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3
Vitamin A supplementation in infants and children 6-59 months of age. Integrated Management of Childhood Illness (IMCI). WHO. https://www.who.int/elena/titles/vitamina_children/en/. Accessed January 7, 2020.
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4
Gottlieb J. Case 4: Reducing child mortality with vitamin A in Nepal. In: Levine R. Case Studies in Global Health: Millions Saved. Sudbury, MA: Jones and Bartlett Publishers; 2007:25-32. https://www.cgdev.org/doc/millions/MS_case_4.pdf. Accessed January 7, 2020.