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Integrated Management of Childhood Illness (IMCI)
Child Health-Approach in RCH-II




               • The IMNCI approach is the
                 centrepiece of newborn and
                 child health strategy in RCH II.
UNDER-FIVE MORTALITY RANKINGS
              COUNTRY                      UNDER-FIVE MORTALITY   RANK
                                                Rate(2007)
             Afghanistan                           257             2
                Nigeria                            189             8
               Pakistan                             90             43
                Bhutan                              84             45
                 India                              72             49
              Bangladesh                            61             58
                 Nepal                              55             62
                  Iraq                              44             66
               Maldives                             30             88
                 China                              22            107
               Sri Lanka                            21            110
               Vietnam                              15            126
               Malaysia                             11            140
The State of the World’s Children- 2009,
                 UNICEF
Recent trends in Neonatal and Infant
             Mortality Rate
 70
          58                    58              57
 60                                                               55                53
 50

 40       37                    37              37                36                35
                                28              28                29                27
 30       26

 20

 10

  0
       SRS 2004           SRS 2005          SRS 2006            SRS 2007         SRS 2008
        Infant Mortality Rate        Neo-Natal Mortality Rate       Early Neo-Natal M.R.



Neonatal Mortality Rate shows stagnation; need to act
IMR high in Bihar, Chhattisgarh, Madhya Pradesh, Orissa,
Rajasthan, Uttar Pradesh and Assam
Infant Mortality Rate
              80


              70
                           70 69
                                            SRS 2008
                                 67
                                      64 63
              60                              57 56
                                                    53
Per 1000 live births




                                                         52 50
              50
                                                                 46 45
                                                                         41
              40
                                                                              35 33
                                                                                      31
              30


              20
                                                                                           12
              10
                                                                                                10

                       0
Distribution of deaths of children less
    than 5 Years, by cause, the world, 1990
             and projected for 2020
The 5 main killers of
children:                     1990                 2020
ARI, diarrhoea,
measles, malaria
and malnutrition

                              55%                  52%
Perinatal
conditions

Other                                   5%                 7%
communicable
                                      9%     18%
diseases                19%
                                12%                        11%
Non-communicable
                                                     11%
diseases

Injuries
For many sick children a single
diagnosis may not be apparent or
          appropriate
  Presenting complaint         Possible cause or associated
                                       condition

 Cough and/or fast breathing         Pneumonia
                                     Severe anaemia
                                     P. falciparum malaria

 Lethargy or unconsciousness         Cerebral malaria
                                     Meningitis
                                     Severe dehydration
                                     Very severe pneumonia

 Measles rash                        Pneumonia
                                     Diarrhoea
                                     Ear infection

 "Very sick" young infant            Pneumonia
                                     Meningitis
                                     Sepsis
WHO/ UNICEF -Integrated Approach
 3 out of 4 children who seek    Integrated Management
  health care are suffering       of Childhood Illness
  from at least one of the five   (IMCI) - Focuses on the
  conditions                      child and not on the
                                  illness
 Some children are often
  suffering from more than one
  condition, making a single
  diagnosis impossible            Integrated
 Such children need complete     Management of
  assessment and combined         Childhood Illness
  therapy for successful          (IMCI) is a cost-
  treatment.
                                  effective approach
Causes of Deaths 0-4 years- 2001-03
            Office of Registrar General, India
                                             Perinatal conditions

                                             Resp Infections
                         2.7 1.5
                 2.8 2.7
           3.2                               Diarrhea
     3.4
                                        33
11                                            Infectious and Parasitic
                                             diseases
                                             Ill defined

                                             Injuries
     14
                                             Nutritional def
                                   22
                                             Malaria

                                             Cong. Anamolies

                                             PUO
Share of under-five mortality in India


Neonatal deaths      Infant deaths within 7 days of birth     40%
50%
                                                                    Infant deaths
                                                                    76%

                        Infant deaths between
                        7 days of birth and within 28 days    10%

                     Infant deaths between 28 days
                     and within one year of birth             26%



                        Child deaths between one
                        year and within five years of birth   24%

 Source : SRS 2007
IMCI to IMNCI-INDIA
                    Major Adaptations
• The entire 0-5 year period covered including the first week of
  life

• 50% of training time for management of young infants (0-2
  months)

• The order of training reversed; now begins with management
  of young infants

• Reduced training duration (8 days), separate training materials
  for physicians & health workers

• Management now consistent with current policies of the
  MOHFW, DWCD and NVBDCP
IMNCI as a key strategy for improving
             child health

Management        Nutrition     Immunization   Other disease
of sick newborn                                 Prevention &
 & children                                    Promotion of
                                                growth and
                                               development


        Integrated Management of
       Neonatal & Childhood Illness
What Needs to be Done in IMNCI

 Improving the case management
  skills of health workers

• Improving the health system for
  effective management of childhood
  illness

• Improving family and community
  practices
Case Management Process
Two groups:

 (A)   Young infants :
       From birth up to 2 months of age.



 (B)   Older children :
       From 2 months up to 5 years of age.
What does IMNCI Offer
• IMNCI guidelines address most but not all of the
  major reasons a sick infant and child is brought to
  a clinic
• Only a limited number of signs based on evidence
  are used to detect a disease
• A combination of individual signs leads to action
  oriented colour coded classification(s)
• IMNCI management includes a limited number of
  drugs and encourages active participation of
  caretakers
• Counselling of caretakers is an essential
  component
Core interventions to improve child
             survival
  • Combating pneumonia/sepsis
  • Combating diarrhoea
  • Nurturing newborns
    (and their mothers)
                                 IMNCI
  • Infant feeding
  • Immunization
  • Combating malaria
Standard Clinical Guidelines
                                  “Golden” paediatric standard

 Complete
examination                                                                                                Advise to
               Preliminary    Laboratory     Differential        Final     Treatment         Treatment
  all signs                                                                                               caretakers
                Diagnosis    examination      Diagnosis        Diagnosis    strategy         procedures
    and                                                                                                   Follow- up
  systems




         “IMNCI” approach
 Focused Assessment             Classification              Treatment       Counsel & Follow-up
        Danger signs              Need to Refer
                                                               Identify                 Counsel
       Main Symptoms
                                Specific treatment           treatment                 Caretakers
      Nutritional status
                                                                 Treat                 Follow-up
     immunisation status
                                Home management
       other problems




                                      • Essential Investigations
Case Management Process

 Assess  the Child.
 Classify the Illness.

 Identify Treatment.

 Treat the Child.

 Counsel the Mother

 Give Follow-Up
 Care.
Assess the Child

Tools for
 assessment:
 Ask,

 Look,

 Listen,   and
 Feel.
Classify The Illness

 “Classify the illness” means making a decision
  on the severity of the illness according to the
  child’s major symptoms.
 Classifications are not diagnoses.

 They are categories that are used to
  determine treatment.
PINK: Patient requires URGENT hospitalization.
Give pre-referral treatment and

Refer URGENTLY to hospital.


YELLOW: Specific medical treatment and advice,
        as you do in your OPD or Clinic.
GREEN: Simple advice on home-management.
   May require some home made safe remedy.
IDENTIFY TREATMENT
   This is further direction to management
   If a child needs urgent referral (hospitalization),
    give pre-referral treatment
   If a child needs treatment at home, explain
    mother how to do it home
   If a child needs immunization, give it
TREAT THE CHILD
   This explains complete treatment to be given at
    clinic and at home
   This includes teaching the mother (or caretaker)
    how to give oral drugs, how to feed and give
    fluid during illness, and how to treat local
    infection at home
   Return for follow up
   When to return immediately
COUNSEL THE MOTHER
   Assess and Counsel the
    mother to solve any
    feeding problem found
   Counsel on home care
   Counsel on when to
    return immediately
   Counsel the mother about
    her own health
Classify ALL YOUNG INFANTS
                         SIGNS                                  CLASSIFY AS
 Convulsion or
 Fast Breathing (60 breaths per minute or more) or           POSSIBLE SERIOUS
 Severe chest indrawing or                                  BACTERIAL INFECTION
 Nasal flaring or

 Grunting or

 Bulging fontanel or

 10 or more skin pustules or a big boil or

 If axillary temperature 37.50C or above (or feels hot to
  touch) or temperature less than 35.50C (or feels cold to
  touch) or
 Lethargic or unconscious or

 Less than normal movement




o Umbilicus red or draining pus or                            LOCAL BACTERIAL
o Pus discharge from ear or                                      INFECTION
o < 10 skin pustules
Classification- Pneumonia
VIDEOS & PHOTO BOOK
               Good attachment to Breast
        lower lip is curled outward   baby’s mouth is wide open




chin touches                                                      lower portion of
the breast                                                        the areola is not
                                                                  visible
VIDEOS & PHOTO BOOK
Poor attachment to Breast
VIDEOS & PHOTO BOOK
Breastfeeding- Correct Positioning
Is this baby well positioned ?
VIDEOS & PHOTO BOOK
SKIN PINCH- DEHYDRATION ASSESSMENT
VIDEOS & PHOTO BOOK
MORE THAN 10 SKIN PUSTULES
Integrated Management of Childhood Illness (IMCI)
VIDEO


• GRUNTING- Short expiratory sound, signifies
  infant having difficulty in breathing- Severe
  illness

• 2 Grunting.wmv
VIDEO


SIGNS OF SEVERE PNEUMONIA
• CHEST INDRAWING- Lower chest wall goes in
  during inspiration
• STRIDOR- Harsh sound when child breathes in

• 2 Severe Respiratory Distress_Large.wmv
VIDEO


• VISIBLE SEVERE WASTING- severe wasting of
  the shoulders, arms buttocks and legs with
  ribs easily seen- MARASMUS



• 11Severe malnutrition_Large.wmv
REMEMBER- SEVERE CLASSIFICATIONS
Sick Young Infant age up        Sick Child age 2 months up
to 2 months                     to 5 years
• Possible serious bacterial     • Severe Pneumonia Or Very
  infection                        Severe Disease
                                 • Severe Dehydration with
• Severe Jaundice                  another severe classification
• Severe Dehydration             • Severe Persistent Diarrhea
• Severe Persistent Diarrhea     • Very Severe Febrile Disease
• Severe Dysentery               • Severe Complicated Measles
• Not able to feed- Possible     • Mastoiditis
  serious bacterial infection    • Severe Malnutrition
  OR Severe Malnutrition         • Severe Anemia

   ACTION- PRE- REFERRAL TREATMENT & URGENT
                   REFERRAL
Hospital is the best place for
treating a very sick infant/child


   But if Referral is not possible,
 IMNCI Guidelines can save a life !
TAKE HOME MESSAGE
   IMNCI--Colour coded case management
                  strategy
• PINK CLASSIFICATION: Child needs inpatient care,
  Provide Pre-referral treatment and Refer Urgently

• YELLOW CLASSIFICATION: Child needs specific
  treatment, provide it at home (e.g. antibiotics, anti-
  malarial, ORT)

• GREEN CLASSIFICATION: Child needs no medicine,
  advise home care
CONCLUSION
 The IMNCI Strategy focuses on the diseases of
  the childhood that cause the greatest global
  burden.
 An integrated approach is needed because the
  overlap in the signs and symptoms of the
  major diseases is common.
Conclusion (continued)
 It is important to treat the child as a whole,
  not simply the most apparent disease.
 The IMNCI approach ensures a complete
  assessment of a sick child, provision of
  treatment and counseling the mother to
  improve health practices at home and to
  promote health seeking behavior.
THANK YOU

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Integrated Management of Childhood Illness (IMCI)

  • 2. Child Health-Approach in RCH-II • The IMNCI approach is the centrepiece of newborn and child health strategy in RCH II.
  • 3. UNDER-FIVE MORTALITY RANKINGS COUNTRY UNDER-FIVE MORTALITY RANK Rate(2007) Afghanistan 257 2 Nigeria 189 8 Pakistan 90 43 Bhutan 84 45 India 72 49 Bangladesh 61 58 Nepal 55 62 Iraq 44 66 Maldives 30 88 China 22 107 Sri Lanka 21 110 Vietnam 15 126 Malaysia 11 140 The State of the World’s Children- 2009, UNICEF
  • 4. Recent trends in Neonatal and Infant Mortality Rate 70 58 58 57 60 55 53 50 40 37 37 37 36 35 28 28 29 27 30 26 20 10 0 SRS 2004 SRS 2005 SRS 2006 SRS 2007 SRS 2008 Infant Mortality Rate Neo-Natal Mortality Rate Early Neo-Natal M.R. Neonatal Mortality Rate shows stagnation; need to act IMR high in Bihar, Chhattisgarh, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and Assam
  • 5. Infant Mortality Rate 80 70 70 69 SRS 2008 67 64 63 60 57 56 53 Per 1000 live births 52 50 50 46 45 41 40 35 33 31 30 20 12 10 10 0
  • 6. Distribution of deaths of children less than 5 Years, by cause, the world, 1990 and projected for 2020 The 5 main killers of children: 1990 2020 ARI, diarrhoea, measles, malaria and malnutrition 55% 52% Perinatal conditions Other 5% 7% communicable 9% 18% diseases 19% 12% 11% Non-communicable 11% diseases Injuries
  • 7. For many sick children a single diagnosis may not be apparent or appropriate Presenting complaint Possible cause or associated condition Cough and/or fast breathing Pneumonia Severe anaemia P. falciparum malaria Lethargy or unconsciousness Cerebral malaria Meningitis Severe dehydration Very severe pneumonia Measles rash Pneumonia Diarrhoea Ear infection "Very sick" young infant Pneumonia Meningitis Sepsis
  • 8. WHO/ UNICEF -Integrated Approach  3 out of 4 children who seek Integrated Management health care are suffering of Childhood Illness from at least one of the five (IMCI) - Focuses on the conditions child and not on the illness  Some children are often suffering from more than one condition, making a single diagnosis impossible Integrated  Such children need complete Management of assessment and combined Childhood Illness therapy for successful (IMCI) is a cost- treatment. effective approach
  • 9. Causes of Deaths 0-4 years- 2001-03 Office of Registrar General, India Perinatal conditions Resp Infections 2.7 1.5 2.8 2.7 3.2 Diarrhea 3.4 33 11 Infectious and Parasitic diseases Ill defined Injuries 14 Nutritional def 22 Malaria Cong. Anamolies PUO
  • 10. Share of under-five mortality in India Neonatal deaths Infant deaths within 7 days of birth 40% 50% Infant deaths 76% Infant deaths between 7 days of birth and within 28 days 10% Infant deaths between 28 days and within one year of birth 26% Child deaths between one year and within five years of birth 24% Source : SRS 2007
  • 11. IMCI to IMNCI-INDIA Major Adaptations • The entire 0-5 year period covered including the first week of life • 50% of training time for management of young infants (0-2 months) • The order of training reversed; now begins with management of young infants • Reduced training duration (8 days), separate training materials for physicians & health workers • Management now consistent with current policies of the MOHFW, DWCD and NVBDCP
  • 12. IMNCI as a key strategy for improving child health Management Nutrition Immunization Other disease of sick newborn Prevention & & children Promotion of growth and development Integrated Management of Neonatal & Childhood Illness
  • 13. What Needs to be Done in IMNCI  Improving the case management skills of health workers • Improving the health system for effective management of childhood illness • Improving family and community practices
  • 14. Case Management Process Two groups: (A) Young infants : From birth up to 2 months of age. (B) Older children : From 2 months up to 5 years of age.
  • 15. What does IMNCI Offer • IMNCI guidelines address most but not all of the major reasons a sick infant and child is brought to a clinic • Only a limited number of signs based on evidence are used to detect a disease • A combination of individual signs leads to action oriented colour coded classification(s) • IMNCI management includes a limited number of drugs and encourages active participation of caretakers • Counselling of caretakers is an essential component
  • 16. Core interventions to improve child survival • Combating pneumonia/sepsis • Combating diarrhoea • Nurturing newborns (and their mothers) IMNCI • Infant feeding • Immunization • Combating malaria
  • 17. Standard Clinical Guidelines “Golden” paediatric standard Complete examination Advise to Preliminary Laboratory Differential Final Treatment Treatment all signs caretakers Diagnosis examination Diagnosis Diagnosis strategy procedures and Follow- up systems “IMNCI” approach Focused Assessment Classification Treatment Counsel & Follow-up Danger signs Need to Refer Identify Counsel Main Symptoms Specific treatment treatment Caretakers Nutritional status Treat Follow-up immunisation status Home management other problems • Essential Investigations
  • 18. Case Management Process  Assess the Child.  Classify the Illness.  Identify Treatment.  Treat the Child.  Counsel the Mother  Give Follow-Up Care.
  • 19. Assess the Child Tools for assessment:  Ask,  Look,  Listen, and  Feel.
  • 20. Classify The Illness  “Classify the illness” means making a decision on the severity of the illness according to the child’s major symptoms.  Classifications are not diagnoses.  They are categories that are used to determine treatment.
  • 21. PINK: Patient requires URGENT hospitalization. Give pre-referral treatment and Refer URGENTLY to hospital. YELLOW: Specific medical treatment and advice, as you do in your OPD or Clinic. GREEN: Simple advice on home-management. May require some home made safe remedy.
  • 22. IDENTIFY TREATMENT  This is further direction to management  If a child needs urgent referral (hospitalization), give pre-referral treatment  If a child needs treatment at home, explain mother how to do it home  If a child needs immunization, give it
  • 23. TREAT THE CHILD  This explains complete treatment to be given at clinic and at home  This includes teaching the mother (or caretaker) how to give oral drugs, how to feed and give fluid during illness, and how to treat local infection at home  Return for follow up  When to return immediately
  • 24. COUNSEL THE MOTHER  Assess and Counsel the mother to solve any feeding problem found  Counsel on home care  Counsel on when to return immediately  Counsel the mother about her own health
  • 25. Classify ALL YOUNG INFANTS SIGNS CLASSIFY AS  Convulsion or  Fast Breathing (60 breaths per minute or more) or POSSIBLE SERIOUS  Severe chest indrawing or BACTERIAL INFECTION  Nasal flaring or  Grunting or  Bulging fontanel or  10 or more skin pustules or a big boil or  If axillary temperature 37.50C or above (or feels hot to touch) or temperature less than 35.50C (or feels cold to touch) or  Lethargic or unconscious or  Less than normal movement o Umbilicus red or draining pus or LOCAL BACTERIAL o Pus discharge from ear or INFECTION o < 10 skin pustules
  • 27. VIDEOS & PHOTO BOOK Good attachment to Breast lower lip is curled outward baby’s mouth is wide open chin touches lower portion of the breast the areola is not visible
  • 28. VIDEOS & PHOTO BOOK Poor attachment to Breast
  • 29. VIDEOS & PHOTO BOOK Breastfeeding- Correct Positioning
  • 30. Is this baby well positioned ?
  • 31. VIDEOS & PHOTO BOOK SKIN PINCH- DEHYDRATION ASSESSMENT
  • 32. VIDEOS & PHOTO BOOK MORE THAN 10 SKIN PUSTULES
  • 34. VIDEO • GRUNTING- Short expiratory sound, signifies infant having difficulty in breathing- Severe illness • 2 Grunting.wmv
  • 35. VIDEO SIGNS OF SEVERE PNEUMONIA • CHEST INDRAWING- Lower chest wall goes in during inspiration • STRIDOR- Harsh sound when child breathes in • 2 Severe Respiratory Distress_Large.wmv
  • 36. VIDEO • VISIBLE SEVERE WASTING- severe wasting of the shoulders, arms buttocks and legs with ribs easily seen- MARASMUS • 11Severe malnutrition_Large.wmv
  • 37. REMEMBER- SEVERE CLASSIFICATIONS Sick Young Infant age up Sick Child age 2 months up to 2 months to 5 years • Possible serious bacterial • Severe Pneumonia Or Very infection Severe Disease • Severe Dehydration with • Severe Jaundice another severe classification • Severe Dehydration • Severe Persistent Diarrhea • Severe Persistent Diarrhea • Very Severe Febrile Disease • Severe Dysentery • Severe Complicated Measles • Not able to feed- Possible • Mastoiditis serious bacterial infection • Severe Malnutrition OR Severe Malnutrition • Severe Anemia ACTION- PRE- REFERRAL TREATMENT & URGENT REFERRAL
  • 38. Hospital is the best place for treating a very sick infant/child But if Referral is not possible, IMNCI Guidelines can save a life !
  • 39. TAKE HOME MESSAGE IMNCI--Colour coded case management strategy • PINK CLASSIFICATION: Child needs inpatient care, Provide Pre-referral treatment and Refer Urgently • YELLOW CLASSIFICATION: Child needs specific treatment, provide it at home (e.g. antibiotics, anti- malarial, ORT) • GREEN CLASSIFICATION: Child needs no medicine, advise home care
  • 40. CONCLUSION  The IMNCI Strategy focuses on the diseases of the childhood that cause the greatest global burden.  An integrated approach is needed because the overlap in the signs and symptoms of the major diseases is common.
  • 41. Conclusion (continued)  It is important to treat the child as a whole, not simply the most apparent disease.  The IMNCI approach ensures a complete assessment of a sick child, provision of treatment and counseling the mother to improve health practices at home and to promote health seeking behavior.