Child Morbidity and Mortality Rates
Child mortality remains one of the most critical global health challenges despite significant progress in recent decades. Understanding the patterns, causes, and interventions related to child morbidity and mortality rates is essential for nursing professionals who work with pediatric populations.
These comprehensive notes examine the current global landscape of child morbidity and mortality rates, analyze contributing factors, and outline evidence-based nursing interventions to improve child health outcomes worldwide.
Definition
Child Mortality Rate: The probability of a child dying between birth and 5 years of age, expressed per 1,000 live births.
Child Morbidity: The incidence of disease or illness within a pediatric population, often measured by prevalence rates of specific conditions.
Global Statistics and Trends
Current Global Picture
Global Child Mortality, 2023
Children died before reaching their fifth birthday
Daily Child Deaths
Children under 5 die every day
Neonatal Deaths
Newborns died in first 28 days of life (2023)
Progress Over Time
Since 1990, the global under-5 mortality rate has dropped by 59%, from 93 deaths per 1,000 live births in 1990 to 37 in 2023. Despite this progress, significant inequalities persist between and within countries.
Geographic Distribution
Approximately 80% of all under-five deaths occur in only 25 countries, with about half occurring in just five countries:
- India
- Nigeria
- Democratic Republic of the Congo
- Pakistan
- China
Regional Disparities
A child born in sub-Saharan Africa is, on average, 18 times more likely to die before the age of 5 than one born in Australia and New Zealand. The risk of under-five death in the highest-mortality country is 80 times greater than in the lowest.
Global Child Mortality Rate Trends
Visualization of under-5 mortality rate decline (1990-2023)
Data source: WHO and UNICEF estimates
Causes of Child Mortality
Leading Causes
The major causes of under-five mortality globally are preventable and treatable through simple, affordable interventions.
Global Causes of Under-5 Mortality
Age-Specific Mortality Distribution
Of the 4.8 million under-five deaths in 2023:
Neonatal Period (0-28 days)
Post-neonatal (1-59 months)
Cause-Specific Analysis
| Cause | Description | Key Interventions |
|---|---|---|
| Preterm Birth Complications | Birth before 37 completed weeks of gestation, leading to respiratory distress, thermoregulation issues, and feeding difficulties | Antenatal corticosteroids, kangaroo mother care, surfactant therapy, antibiotics for premature rupture of membranes |
| Pneumonia | Acute respiratory infection affecting the lungs, often caused by viruses or bacteria | Antibiotics, oxygen therapy, vaccination (Hib, pneumococcal), improved nutrition, reduced indoor air pollution |
| Intrapartum-related Events | Complications during labor and delivery, including birth asphyxia and birth trauma | Skilled birth attendance, emergency obstetric care, neonatal resuscitation, clean birth practices |
| Diarrheal Diseases | Gastrointestinal infections leading to frequent loose stools, dehydration, and electrolyte imbalances | ORS, zinc supplementation, improved water and sanitation, rotavirus vaccination, continued feeding |
| Malaria | Parasitic infection transmitted by female Anopheles mosquitoes, causing fever, anemia, and organ damage | Insecticide-treated bed nets, antimalarial drugs, intermittent preventive treatment, prompt diagnosis and treatment |
| Malnutrition | Inadequate intake of nutrients leading to stunting, wasting, and micronutrient deficiencies | Breastfeeding promotion, complementary feeding, vitamin A supplementation, management of severe acute malnutrition |
Risk Factors
Multiple interconnected factors influence child morbidity and mortality rates, creating a complex web of vulnerabilities that affect child survival.
Socioeconomic Factors
- Poverty and low household income
- Maternal education level
- Geographic location (rural vs. urban)
- Access to healthcare services
- Food insecurity
- Gender inequality
Maternal Factors
- Adolescent pregnancy
- Short birth intervals
- Maternal nutritional status
- Maternal health conditions
- Lack of antenatal care
- Unassisted deliveries
Environmental Factors
- Unsafe water sources
- Poor sanitation facilities
- Indoor air pollution
- Exposure to infectious disease vectors
- Climate-related hazards
- Inadequate housing conditions
Health System Factors
- Quality of healthcare services
- Distance to health facilities
- Cost of healthcare
- Availability of essential medicines
- Healthcare worker shortages
- Weak referral systems
Critical Risk Multipliers
Certain factors significantly increase the risk of child mortality when present in combination:
- Poverty + Poor Water/Sanitation: 2-4x increased risk of diarrheal disease mortality
- Malnutrition + Infectious Disease: Up to 11x higher risk of death compared to well-nourished children
- Low Birth Weight + Preterm Birth: 3-10x increased risk of neonatal mortality
- Limited Access to Healthcare + Acute Illness: 5x higher mortality from treatable conditions
SDG Targets for Child Mortality
Sustainable Development Goal 3.2
“By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce:
- Neonatal mortality to at least as low as 12 per 1,000 live births
- Under-5 mortality to at least as low as 25 per 1,000 live births”
Current Progress
While global progress has been made toward reducing child morbidity and mortality rates, many countries remain off-track to meet the SDG targets by 2030.
| Region | Under-5 Mortality Rate (2023) | Neonatal Mortality Rate (2023) | On Track for SDG Target? |
|---|---|---|---|
| Sub-Saharan Africa | 74 | 27 | No |
| South Asia | 39 | 24 | No |
| Middle East & North Africa | 21 | 13 | Partially |
| East Asia & Pacific | 14 | 7 | Yes |
| Latin America & Caribbean | 16 | 9 | Yes |
| North America | 6 | 4 | Yes |
| Europe | 5 | 3 | Yes |
Key Accelerators for SDG Achievement
- Universal Health Coverage: Ensuring all children have access to quality healthcare services without financial hardship
- Integrated Service Delivery: Combining interventions across the continuum of care from pregnancy through childhood
- Community Engagement: Mobilizing communities to adopt healthy practices and seek care appropriately
- Multi-sectoral Approach: Addressing underlying determinants through collaboration across health, education, water/sanitation, and social protection sectors
- Data-driven Decision Making: Strengthening health information systems to identify and target vulnerable populations
Measurement Methods for Child Mortality
Accurate measurement of child morbidity and mortality rates is essential for tracking progress, identifying vulnerable populations, and informing policy and program decisions.
Direct Methods
Uses data on:
- Date of birth of children
- Survival status
- Dates of death or ages at death of deceased children
Commonly used in countries with reliable vital registration systems
Indirect Methods
Uses information on:
- Survival status of children to specific cohorts of mothers
- Typically age cohorts or time since first birth cohorts
- Model age patterns of fertility and child mortality
Used in countries with limited vital registration data
Key Mortality Indicators
| Indicator | Definition | Calculation |
|---|---|---|
| Neonatal Mortality Rate (NMR) | Probability of dying within the first 28 days of life | Number of deaths of infants under one month of age per 1,000 live births |
| Infant Mortality Rate (IMR) | Probability of dying between birth and exactly one year of age | Number of deaths of infants under one year of age per 1,000 live births |
| Under-Five Mortality Rate (U5MR) | Probability of dying between birth and exactly five years of age | Number of deaths of children under five years of age per 1,000 live births |
| Child Mortality Rate (CMR) | Probability of dying between exact ages one and five | Number of deaths of children aged 1-4 years per 1,000 children who survived to 12 months of age |
| Cause-Specific Mortality Rate | Probability of dying from a specific cause | Number of deaths from specific cause per 100,000 population of same age group |
Data Sources
Civil Registration and Vital Statistics (CRVS)
Continuous, permanent, and compulsory recording of vital events (births, deaths). Most reliable but often incomplete in low-resource settings.
Population-Based Surveys
DHS, MICS, and other household surveys that collect retrospective birth histories. Primary source in countries with inadequate CRVS.
Health Facility Data
Routine health information systems, hospital records. Often incomplete as many deaths occur outside health facilities.
Measurement Challenges
- Underreporting: Particularly common for neonatal deaths and stillbirths
- Recall Bias: In survey-based methods, mothers may not accurately recall dates or events
- Attribution of Cause: Difficult to determine exact cause of death without proper diagnosis
- Incomplete Coverage: Many deaths occur at home without medical attention
- Data Quality: Inconsistent definitions and poor recording practices
Preventable Factors
The majority of child morbidity and mortality is attributable to preventable causes and can be addressed through proven, cost-effective interventions.
Key Preventable Factors
Infectious Diseases
- Vaccine-preventable diseases (measles, pertussis, etc.)
- Diarrheal diseases from contaminated water
- Respiratory infections from poor air quality
- Malaria in endemic regions
- HIV transmission from mother to child
Impact: Up to 60% of all under-five deaths are linked to infectious diseases
Nutritional Factors
- Inadequate breastfeeding practices
- Poor complementary feeding
- Micronutrient deficiencies (vitamin A, zinc, iron)
- Protein-energy malnutrition
- Maternal malnutrition affecting birth outcomes
Impact: Malnutrition contributes to approximately 45% of all child deaths
Perinatal Factors
- Lack of skilled birth attendance
- Inadequate antenatal care
- Birth asphyxia and trauma
- Neonatal infections
- Prematurity and low birth weight
Impact: Approximately 40% of under-five deaths occur in the neonatal period
Environmental Factors
- Unsafe water sources
- Poor sanitation facilities
- Indoor air pollution from cooking fuels
- Outdoor air pollution
- Vector breeding sites for disease transmission
Impact: Environmental factors contribute to 26% of annual deaths in children under five
Prevention Potential
Percentage of Deaths Preventable by Intervention
Cost-Effectiveness of Interventions
- $ Vitamin A supplementation: $100 per death averted
- $ ORS for diarrhea: $200 per death averted
- $$ Insecticide-treated bed nets: $600-1,000 per death averted
- $$ Vaccines (basic package): $700-1,500 per death averted
- $$$ Emergency obstetric care: $3,000-6,000 per death averted
Nurse’s Role in Prevention
Nurses are critical in preventing child morbidity and mortality through:
- Education: Teaching families about proper nutrition, hygiene, danger signs, and when to seek care
- Immunization: Administering vaccines according to national schedules and following up on missed doses
- Growth Monitoring: Regular assessment of children’s growth and development to detect issues early
- Case Management: Identifying and treating common childhood illnesses using protocols like IMCI
- Community Outreach: Reaching vulnerable populations through home visits and community-based care
Nursing Interventions
Assessment
Comprehensive Pediatric Assessment
A thorough assessment is the foundation for identifying risk factors and implementing appropriate interventions to reduce child morbidity and mortality.
Physical Assessment
- Vital signs: temperature, pulse, respiration, blood pressure
- Weight, height, and head circumference (plot on growth charts)
- General appearance, activity level, and behavior
- Systematic examination of all body systems
- Developmental milestone assessment
Nutritional Assessment
- Current feeding practices (breastfeeding, complementary foods)
- Dietary intake and food security
- Signs of micronutrient deficiencies
- Anthropometric measurements (weight-for-age, height-for-age, weight-for-height)
- MUAC (Mid-Upper Arm Circumference) for children 6-59 months
Environmental Assessment
- Water source and sanitation facilities
- Housing conditions and ventilation
- Exposure to indoor air pollution
- Vector breeding sites (for malaria, dengue)
- Access to healthcare services
Social Assessment
- Family structure and support systems
- Caregiver knowledge, attitudes, and practices
- Socioeconomic status and resource availability
- Cultural beliefs and practices related to child health
- Barriers to healthcare access
Risk Factor Assessment
- Immunization status
- Previous illnesses and hospitalizations
- Exposure to communicable diseases
- Danger signs of common childhood illnesses
- Maternal health status (for infants)
IMCI Assessment Approach
The Integrated Management of Childhood Illness (IMCI) provides a structured approach to assessing sick children for common illnesses that contribute to child morbidity and mortality.
| Assessment Step | Key Components | Nursing Action |
|---|---|---|
| Check for General Danger Signs | Inability to drink/breastfeed, vomiting everything, convulsions, lethargy/unconsciousness | If any danger sign present, provide urgent treatment and refer immediately |
| Assess for Main Symptoms | Cough/difficulty breathing, diarrhea, fever, ear problems | Classify severity based on signs and symptoms; follow treatment protocols |
| Check Nutritional Status | Weight-for-age, visible severe wasting, edema of both feet, palmar pallor | Classify malnutrition and anemia; provide appropriate nutritional advice |
| Check Immunization Status | Review vaccination record against national schedule | Administer due vaccines; plan for missed vaccinations |
| Assess Other Problems | Any other concerns reported by caregiver | Address additional health issues; refer if needed |
Breastfeeding Promotion and Support
Breastfeeding is one of the most effective interventions for reducing child morbidity and mortality rates. Exclusive breastfeeding for the first six months, followed by continued breastfeeding with appropriate complementary foods, can prevent approximately 13% of all under-five deaths.
Evidence Impact
- Exclusive breastfeeding for 6 months reduces risk of diarrhea by 50-60%
- Reduces risk of respiratory infections by 30-50%
- Children who are not breastfed are 14 times more likely to die from all causes compared to exclusively breastfed infants
- Early initiation of breastfeeding (within 1 hour of birth) can reduce neonatal mortality by up to 22%
Nursing Interventions for Breastfeeding Support
- Antenatal Education: Provide information about benefits of breastfeeding and prepare mothers
- Early Initiation: Support skin-to-skin contact and breastfeeding within first hour after birth
- Lactation Support: Assist with proper positioning, latch, and management of common breastfeeding problems
- Exclusive Breastfeeding: Discourage introduction of formula, water, or other foods for first 6 months
- Continued Breastfeeding: Encourage breastfeeding until at least 2 years of age alongside complementary foods
- Problem-solving: Address challenges such as perceived insufficient milk, sore nipples, or breast engorgement
Counseling Techniques
Effective counseling can increase exclusive breastfeeding rates by up to 90%. Use these techniques:
- Listen and Learn: Use open-ended questions, reflect back what mothers say, show empathy
- Build Confidence: Accept what a mother thinks and feels, give practical help, use simple language
- Give Support: Praise what is being done well, give relevant information, offer suggestions not commands
- Individual Counseling: One-on-one support increases exclusive breastfeeding by 60%
- Group Counseling: Group education and support increases exclusive breastfeeding by 74%
Common Breastfeeding Challenges and Solutions
| Challenge | Assessment | Nursing Intervention |
|---|---|---|
| Perceived Insufficient Milk | Check baby’s weight gain, urine output, and effective suckling | Educate on demand feeding, proper positioning, and signs of adequate intake; increase frequency of feeding |
| Sore/Cracked Nipples | Observe breastfeeding session, check for signs of thrush | Correct positioning and latch; apply expressed breast milk to nipples; start feeding on less sore side |
| Engorgement | Check for hard, painful, warm breasts | Frequent feeding; cold compresses after feeding; warm compresses before feeding; gentle massage |
| Mastitis | Check for localized pain, redness, fever | Continue breastfeeding; adequate rest and fluids; cold compresses; antibiotics if indicated |
| Working Mothers | Assess work schedule and available support | Teach expression and storage of breast milk; maximize feeding when with baby; support workplace policies |
BREAST-FEED Mnemonic for Support
- B – Benefits discussion with mother
- R – Right positioning and attachment
- E – Exclusive breastfeeding for 6 months
- A – Assessment of effective feeding
- S – Support systems identification
- T – Techniques for expressing milk
- F – Frequency on demand
- E – Education about potential problems
- E – Encouragement and confidence building
- D – Documentation of progress
Nutrition Support and Interventions
Malnutrition is associated with 45% of all child deaths. Addressing nutritional deficiencies is crucial for reducing child morbidity and mortality rates.
Complementary Feeding Support
The period of complementary feeding (6-24 months) is a critical window for preventing malnutrition and growth faltering.
Nursing Interventions
- Educate on appropriate timing for introduction of complementary foods (at 6 months)
- Counsel on food diversity, frequency, consistency, and quantity appropriate for age
- Demonstrate preparation of nutrient-dense foods using locally available ingredients
- Promote responsive feeding practices (recognizing and responding to hunger cues)
- Address feeding during and after illness
- Monitor growth regularly and adjust recommendations as needed
Evidence Impact
- Education on complementary feeding in food-secure populations improves height gain by 0.35 standard deviations
- In food-insecure populations, provision of complementary food with education reduces stunting by 29%
- Appropriate complementary feeding could prevent approximately 6% of under-five deaths
Micronutrient Supplementation
Addressing specific micronutrient deficiencies significantly reduces child morbidity and mortality.
| Micronutrient | Dosage & Timing | Impact on Mortality |
|---|---|---|
| Vitamin A | 100,000 IU for 6-11 months; 200,000 IU for 12-59 months every 4-6 months | Reduces all-cause mortality by 24-30%; diarrhea mortality by 28-33% |
| Zinc (Preventive) | 10-20 mg daily for 2 weeks | Reduces diarrhea mortality by 23%; pneumonia mortality by 15% |
| Zinc (Therapeutic) | 10-20 mg daily for 10-14 days during diarrhea | Reduces duration of diarrhea by 25%; reduces severe episodes by 27% |
| Iron (with folic acid) | 12.5 mg iron + 50 μg folic acid daily for 6-24 months | Reduces anemia by 40%; improves cognitive development |
Important Considerations
- Iron supplementation should be combined with malaria prevention in endemic areas
- Vitamin A should not be given to infants under 6 months except those with measles, severe malnutrition, or xerophthalmia
- Multiple micronutrient powders (MNPs) may be used as an alternative to single supplements
- Food fortification (e.g., iodized salt, fortified flours) should be promoted as a sustainable approach
The First 1000 Days Approach
The period from conception to a child’s second birthday (the first 1000 days) represents a critical window of opportunity for nutritional interventions to have the greatest impact on reducing child morbidity and mortality rates.
Pregnancy
- Iron-folic acid supplementation
- Adequate protein and energy intake
- Iodine supplementation in deficient areas
- Calcium supplementation for preeclampsia prevention
- Deworming in endemic areas
0-6 Months
- Early initiation of breastfeeding
- Exclusive breastfeeding
- Support for lactating mothers
- Growth monitoring
- Vitamin A supplementation for mother
6-24 Months
- Continued breastfeeding
- Appropriate complementary feeding
- Micronutrient supplementation
- Prevention and treatment of infections
- Regular growth monitoring
Key Nursing Actions for Nutrition Support
- Assess nutritional status of all children during every healthcare encounter
- Educate caregivers on age-appropriate feeding practices
- Demonstrate preparation of nutrient-dense complementary foods
- Administer micronutrient supplements according to protocols
- Monitor growth regularly and identify faltering early
- Support mothers to continue breastfeeding while introducing complementary foods
- Identify and refer cases of severe acute malnutrition promptly
- Follow up with high-risk children to ensure adherence to recommendations
Immunization and Vaccination
Immunization is one of the most cost-effective interventions for reducing child morbidity and mortality rates, preventing an estimated 2-3 million deaths annually. Expanding coverage could prevent an additional 1.5 million deaths.
Core Vaccines in EPI (Expanded Program on Immunization)
| Vaccine | Prevents | Mortality Reduction |
|---|---|---|
| BCG | Tuberculosis | 50% reduction in TB mortality |
| Hepatitis B | Hepatitis B infection | Prevents chronic infection and liver cancer |
| Polio (OPV/IPV) | Poliomyelitis | 99% global reduction in polio cases |
| DPT/Pentavalent | Diphtheria, Pertussis, Tetanus, Hib, Hep B | 80% reduction in pertussis deaths |
| Measles | Measles | 85% reduction in measles mortality |
| Rotavirus | Rotavirus diarrhea | 74% reduction in rotavirus deaths |
| PCV | Pneumococcal disease | 65% reduction in invasive pneumococcal disease |
Nursing Interventions for Immunization
Before Vaccination
- Review immunization history and identify due vaccines
- Screen for contraindications and precautions
- Educate caregivers about vaccines to be given
- Obtain informed consent
- Prepare vaccines according to manufacturer guidelines
- Check expiry dates and vaccine appearance
During Vaccination
- Position child appropriately (parent’s lap, comfort hold)
- Use correct administration technique (route, site, needle size)
- Implement pain management strategies (breastfeeding, distraction)
- Observe for immediate adverse reactions
- Dispose of sharps safely
After Vaccination
- Record vaccines given in child’s health record
- Inform caregiver about potential side effects and management
- Schedule next vaccination appointment
- Implement tracking system for defaulters
- Report adverse events following immunization (AEFI)
Strategies to Improve Immunization Coverage
Health System Strategies
- Ensure consistent vaccine supply
- Maintain cold chain integrity
- Train health workers in safe injection practices
- Implement regular outreach services
- Integrate with other child health services
- Use electronic immunization registries
Community Strategies
- Community mobilization campaigns
- Engage community leaders and influencers
- Use community health workers for tracking
- Address cultural barriers and misconceptions
- Conduct home visits for defaulters
- Establish community accountability mechanisms
Family Strategies
- Educate on importance of complete vaccination
- Use reminder systems (SMS, phone calls)
- Provide vaccination cards and emphasize keeping them
- Address concerns about vaccine safety
- Reduce opportunity costs (combine services)
- Involve fathers and extended family members
Addressing Vaccine Hesitancy
Vaccine hesitancy is a growing threat to global immunization efforts and can lead to increased child morbidity and mortality rates. Nurses should:
- Listen to caregiver concerns without judgment
- Acknowledge fears and validate emotions
- Provide accurate, evidence-based information
- Use clear, simple language to explain benefits and risks
- Share personal experiences with vaccination (if applicable)
- Address misconceptions and misinformation promptly
- Emphasize protection for both individual child and community
Infection Prevention and Control
Infectious diseases remain leading causes of child morbidity and mortality, particularly in resource-limited settings. Effective infection prevention and control measures can substantially reduce disease burden.
Pneumonia Management
Pneumonia is responsible for 16% of all under-five deaths globally.
Assessment
- Count respiratory rate for full minute (age-specific cutoffs for fast breathing)
- Look for chest indrawing (severe pneumonia)
- Check for danger signs: inability to drink, convulsions, abnormal sleepiness
- Assess for stridor, wheezing, oxygen saturation if available
- Check for malnutrition, which increases pneumonia mortality
Nursing Interventions
- Non-severe pneumonia: Oral antibiotics (amoxicillin) for 5 days
- Severe pneumonia: Refer urgently with first dose of antibiotics
- Support respiratory function (positioning, clearing secretions)
- Provide adequate fluids and nutritional support
- Administer oxygen if available and saturation <90%
- Monitor for signs of deterioration
- Educate caregivers on recognition of danger signs
Diarrhea Management
Diarrheal diseases cause 8% of all under-five deaths globally.
Assessment
- Assess hydration status: skin pinch, sunken eyes, level of consciousness
- Determine type of diarrhea: acute watery, persistent (>14 days), dysentery (bloody)
- Check for associated symptoms: fever, vomiting, abdominal pain
- Assess ability to drink and take oral medications
- Screen for malnutrition
Nursing Interventions
- ORS: Cornerstone of treatment; reduced osmolarity WHO formula
- Zinc supplementation: 10-20mg daily for 10-14 days
- Continued feeding during and after diarrhea episode
- IV fluids for severe dehydration or inability to drink
- Antibiotics only for dysentery or suspected cholera
- Monitor hydration status and response to treatment
- Educate on handwashing, safe water, and food hygiene
Malaria Prevention and Management
Malaria causes approximately 5% of under-five deaths globally, primarily in sub-Saharan Africa.
Prevention
- ITNs (Insecticide-Treated Nets): Distribute and promote consistent use
- IRS (Indoor Residual Spraying): Implement in high-transmission areas
- IPTc (Intermittent Preventive Treatment for children): Seasonal chemoprevention in areas with seasonal transmission
- Environmental management: Eliminate breeding sites
- Education on protection from mosquito bites
Diagnosis
- Test all suspected cases with RDT or microscopy
- Consider malaria in any child with fever in endemic areas
- Do not rely on clinical diagnosis alone
- Check for signs of severe malaria:
- Impaired consciousness
- Respiratory distress
- Multiple convulsions
- Prostration
- Shock
Treatment
- Uncomplicated malaria: ACT (Artemisinin-based Combination Therapy) for 3 days
- Severe malaria: Parenteral artesunate, artemether, or quinine; refer urgently
- Monitor response to treatment
- Ensure completion of full treatment course
- Manage fever with antipyretics
- Provide supportive care and adequate hydration
Integrated Management of Childhood Illness (IMCI)
IMCI is a comprehensive approach to child health that aims to reduce death, illness, and disability while promoting improved growth and development among children under five years of age.
Key Components
- Improving case management skills of health workers
- Strengthening health systems to deliver quality care
- Enhancing family and community practices for child health
Process
- Assess the child’s condition
- Classify the illness based on signs and symptoms
- Identify treatment actions
- Treat the child
- Counsel the caregiver
- Follow up with the child as needed
Impact on Child Mortality
- Reduces all-cause mortality by 15-22%
- Reduces pneumonia-specific mortality by 32%
- Improves quality of care delivered to sick children
- Enhances rational use of antibiotics and other medicines
- Increases usage of preventive interventions
- Improves caregiver knowledge and care-seeking behaviors
Nursing Role in IMCI
Nurses are often the primary implementers of IMCI and should be trained in the approach. They serve as the first point of contact for sick children and play a crucial role in assessment, classification, treatment, and counseling.
WASH-HANDS Mnemonic for Infection Prevention
- W – Water safety (treat, boil, filter)
- A – Adequate sanitation facilities
- S – Safe food preparation
- H – Handwashing with soap at critical times
- H – Hygiene education for families
- A – Assess for signs of infection early
- N – Nutritional support during illness
- D – Diarrhea management with ORS and zinc
- S – Seek care promptly for danger signs
Management of Severe Acute Malnutrition
Severe acute malnutrition (SAM) contributes significantly to child morbidity and mortality rates, with case fatality rates of 10-40% when treated in traditional healthcare settings. Evidence-based management can reduce mortality to <5%.
Identification of SAM
| Diagnostic Criteria (Any ONE) | Cut-off | Implications |
|---|---|---|
| Weight-for-height Z-score (WHZ) | < -3 SD | Severe wasting |
| Mid-Upper Arm Circumference (MUAC) | < 115 mm | Strong predictor of mortality |
| Bilateral pitting edema | Any grade (+, ++, +++) | Kwashiorkor (higher mortality risk) |
Facility-Based Management
For children with SAM with medical complications or edema +++.
10-Step Approach (WHO Protocol)
- Phase 1 (Stabilization)
- Treat/prevent hypoglycemia
- Treat/prevent hypothermia
- Treat/prevent dehydration
- Correct electrolyte imbalance
- Treat infections
- Begin cautious feeding (F-75 formula)
- Correct micronutrient deficiencies
- Transition Phase
- Increase feed volumes
- Introduce RUTF or F-100
- Prepare for rehabilitation phase
- Phase 2 (Rehabilitation)
- Rebuild wasted tissues (catch-up growth)
- Stimulate emotional and developmental rehabilitation
- Prepare for discharge and follow-up
Community-Based Management
For children with SAM without medical complications (approximately 80% of SAM cases).
Community-Based Therapeutic Care
- RUTF (Ready-to-Use Therapeutic Food)
- Provide 150-200 kcal/kg/day
- Typically 2-3 sachets daily for 6-8 weeks
- No need for preparation (eat directly from packet)
- Shelf-stable with no refrigeration required
- Routine Medications
- Broad-spectrum antibiotics
- Vitamin A (except if received in past 6 months)
- Antihelminthic (if >12 months)
- Antimalarial (in endemic areas)
- Measles vaccination (if due)
- Weekly Follow-up to monitor:
- Weight gain (target: >4g/kg/day)
- MUAC
- Edema resolution
- Appetite test
- Clinical condition
Nursing Considerations in SAM Management
Critical Nursing Interventions
- Frequent monitoring of vital signs and clinical status
- Careful fluid management (risk of fluid overload and heart failure)
- Rewarming techniques for hypothermia
- Precise feed preparation and administration
- Infection prevention practices (SAM children highly susceptible)
- Psychosocial stimulation and play therapy
- Accurate documentation of intake, output, and response
Caregiver Education
- RUTF administration (only for the malnourished child)
- Hygiene practices (handwashing, safe food preparation)
- Recognition of danger signs requiring immediate return
- Continued breastfeeding (if applicable)
- Importance of follow-up appointments
- Local nutritious foods for sustainable recovery
- Prevention of future malnutrition episodes
Impact on Child Mortality
- Implementation of WHO protocol for inpatient management reduces case fatality rates from 30-50% to <10%
- Community-based management with RUTF shows recovery rates of >75% and case fatality rates of <5%
- Children treated with RUTF are 51% more likely to achieve nutritional recovery than those receiving standard care
- Early identification and treatment of moderate acute malnutrition can prevent progression to SAM
- Integration of SAM management into routine health services can increase coverage and reduce child mortality rates
Prevention Strategies
Preventing child morbidity and mortality requires a comprehensive approach that addresses underlying determinants, strengthens health systems, and implements proven interventions at scale.
Health System Strengthening
- Improve access to quality primary healthcare
- Train and retain skilled health workers
- Ensure consistent supply of essential medicines
- Strengthen referral systems
- Implement effective supervision and quality improvement
- Enhance health information systems for data-driven decisions
Community Engagement
- Deploy community health workers for outreach
- Implement community-based health education
- Engage community leaders as health champions
- Establish women’s groups for maternal-child health
- Develop community accountability mechanisms
- Support care-seeking behavior change
Multi-sectoral Approach
- Improve water and sanitation infrastructure
- Enhance food security and nutrition
- Expand educational opportunities, especially for girls
- Implement social protection programs
- Address poverty and income inequality
- Develop supportive policies across sectors