integrated management of neonatal and childhood illnesses, Dr KRB
Integrated Management of
Neonatal and Childhood Illness
Plan of presentation
Background for IMCI
Rationale for IMNCI
- Principles of Integrated care
- Elements of case management process
- Case management process chart book
Implementation of IMNCI
IMR Of the world
34.9deaths/1000 live births
• U5MR Of the world
47.8deaths/1000 live births
• Reduce infant and child mortality rates
• Improving child health & survival
• IMR reduced from 114 (1980) to 47 (2010 SRS
bulletin) and now as above.
Background of IMCI
Every year more than 10 million children die in
developing countries before they reach their fifth
7 in 10 of these deaths are due to five preventable
and treatable conditions.
malnutrition – and often to a combination of these
Background of IMCI (Contd…)
The 5 main killers of
In India, common illnesses in children under 3
years of age include fever (27%), acute
respiratory infections (17%), diarrhoea (13%)
Projections based on the 1996 analysis indicate
that common childhood illnesses will continue to
be major contributors to child deaths through the
year 2020 unless greater efforts are made to
Many sick children are not properly assessed
* National Family Health Survey- India, 1998-99 providers, and
and treated by these health care
6** Global Burden of disease, WHO, Geneva, 1996
that their parents are poorly advised.
Rationale for an integrated evidence
based syndromic approach to case
Many well-known prevention and treatment strategies have
already proven effective for saving young lives.
As each of these interventions has been successful,
accumulating evidence suggests that an integrated approach is
needed to manage sick children to achieve better outcomes.
Child health programmes need to move beyond single diseases
to address the overall health and well-being of the child.
Many children present with overlapping signs and symptoms of
diseases, a single diagnosis can be difficult, and may not be
feasible or appropriate. This is especially true for first -level
health facilities where examinations involve few instruments,
negligible laboratory tests, and no X-ray.
During the mid-1990s, WHO in collaboration with UNICEF and
many other agencies, institutions and individuals, responded to
Key features of IMCI
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 5 years of age.
IMCI strategy promotes the accurate identification of
childhood illnesses in out patient settings.
appropriate combined treatment of all
Key features of IMCI (Contd. . .)
Strengthens the counseling of caretakers.
Speeds up the referral of severely ill children.
appropriate care seeking behaviors,
improved nutrition & preventive care & correct
implementation of prescribed care.
Provision of home based newborn care to
promote exclusive breastfeeding
improve illness recognition & timely care seeking
Home visits for young infants:
All newborns: 3 visits (within 24 hours of birth, day 3-4 and
Newborns with low birth weight: 3 more visits on day 14, 21
Source: IMCI; Student’s Handbook, WHO
Incorporation of neonatal care as it now constitutes two
thirds of infant mortality.
Inclusion of 0-7 days.
Incorporating National guidelines on Malaria, Anemia,
Vitamin A supplementation and Immunization schedule.
Training begins with sick young infant up to 2 months.
Proportion of training time devoted to sick young infant
and sick child is almost equal.
Difference between IMCI and IMNCI
WHO – UNICEF IMCI
Coverage of 0 to 6 days (early
Basic Health Care Module
Home visit by the provider for
newborn and Young Infant
Training Home based Care
Training days for newborn and 2 out of 11 days
Sequence of training
4 out of 11 days
Child (2 months to 5 years of
Newborn and young infants (0
age) then Young infant ( 7 days to 2 months).Then Child (from
to 2 months of age)
2 months to 5 years of age.)
Up to 50%
deaths are in
the first 24 hours
75% of neonatal
deaths are in
the first week –
3 million deaths
when most babies die is
of care is lowest
Guidelines for IMNCI
Evidence-based, syndromic approach to case
management that includes rational, effective and
affordable use of drugs and diagnostic tools.
Evidence - based medicine stresses the
importance of evaluation of evidence from clinical
research and cautions against the use of intuition,
unsystematic clinical experience, and untested
pathophysiologic reasoning for medical decisionmaking.
In situations where laboratory support and clinical
resources are limited, the syndromic approach is
a more realistic and cost-effective way to manage
An evidence-based syndromic approach can be
used to determine the:
• Health problem(s) the child may have.
• Severity of the child’s condition, and
• Actions that can be taken to care for the child (e.g.
refer the child immediately, manage with available
resources, or manage at home).
In addition, IMNCI promotes:
• Adjustment of interventions to the capacity of the
health system, and
• Active involvement of family members and the
community in the health care process.
Components of IMNCI strategy
Improvements in the case-management
skills of health staff through the provision of
locally-adapted guidelines on Integrated
Management of Neonatal and Childhood
Illness and activities to promote their use.
ii. Improvements in the overall health system
required for effective management of
neonatal and childhood illness.
iii. Improvements in family and community
health care practices.
Principles of integrated care
All sick young infants up to 2 months of age must be
assessed for “possible bacterial infection / jaundice”.
Then they must be routinely assessed for the major
All sick children age 2 months up to 5 years must be
examined for “general danger signs” which indicate
the need for immediate referral or admission to a
hospital. They must then be routinely assessed for
major symptoms: cough or difficult breathing,
diarrhoea, fever and ear problems.
Principles of integrated care (Contd.
All sick young infants and children 2 months up
to 5 years must also be routinely assessed for
nutritional and immunization status, feeding
problems, and other potential problems.
Only a limited number of carefully selected
clinical signs are used, based on evidence of
their sensitivity and specificity to detect disease.
A combination of individual signs leads to a
child's classification(s) rather than diagnosis.
Classification indicate the severity of conditions
Principles of integrated care (Contd.
They call for specific actions based on whether the child
- needs urgent hospital referral or admission
( classifies as and colour coded pink)
- needs specific medical Rx or advice
(classified as and colour coded yellow)
- can be managed at home
(classified as and colour coded green)
Use of limited number of essential drugs and encourage
active participation of caretakers in the treatment of
IMNCI is a Key Strategy for Improving Child
of Childhood Illness
Elements of case management
- Child by checking for danger signs.
Classify - Child's illness by color coded triage system.
Identify - Specific treatments.
Treatments- Instructions of oral drugs, feeding & fluids.
Counsel - Mother about breast feeding & about her
own health as
well as to follow further instructions on
further child care.
Follow up care - Reassess the child for new problems.
Counseling a mother or caretaker
Ask and Listen
Essential elements :
Teach how to give oral drugs
Teach how to treat local infection
Teach how to manage breast or nipple problem
Teach correct positioning and
attachment for breastfeeding
Counsel on other feeding problems
Advise when to return
Counsel the mother about her own health
Facility based -IMNCI
Acute shortage of Pediatricians in the country; as
against the required number of 4045 there are only
898 paediatricians in position.*
The introduction of F-IMNCI will help build capacities
of the health personnel at facilities to address new
born and child hood illness and thus help bridge this
acute shortage of specialists.
* Bulletin on Rural Health Statistics
F- IMNCI is an integration of the existing IMNCI package
and the Facility Based Care package in to one.
From November 2009 IMNCI has been re -baptized as FIMNCI, (F -Facility) with added component of:
1. Asphyxia Management and
2. Care of Sick new born at facility level, besides all other
components included under IMNCI
The integrated approach of IMNCI and Facility based care;
(F-IMNCI) therefore provides a continuum of quality care
for severely ill newborns and children from the community
and to the facility.
Majority of the health facilities (24x7 PHCs, FRUs, CHCs
and District hospitals) do not have trained pediatricians
to provide specialized care to the referred sick newborns
54 and children, the F-IMNCI training will therefore help in skill
building of the medical officers and staff nurses posted in
Components of F-IMNCI
Skill based training
Improvements to the health system :
Logistics/Manpower/ Referral mechanisms
Improvement of Family and Community Practices
Training of trainers:
Number to be trained:
C - IMNCI: Community and Household
Community IMNCI is basically Component 3 of the
It aims at improving family and community practices
by promoting those Practices with the greatest
potential for improving child survival, growth and
Evidence that 80% of deaths of children under five
years of age occur at home with little or no contact
with health providers. ( Kirk et al.)
C-IMCI seeks to strengthen the linkage between
health services and communities, to improve
selected family and community practices and to
support and strengthen community-based activities.
C - IMNCI: cont.…
16 key family practices identified Under Four Broad Heading:
The promotion of growth and development of the child:
Exclusive Breastfeeding for six months. Good quality complementary
foods after six months. Continue breastfeeding for two years or
Ensure enough micronutrients – such as vitamin A, iron and zinc – in
diet or through supplements.
Promote mental and social development by responding to a child’s
needs for care and by playing, talking and providing a stimulating
Dispose of all faeces safely, wash hands after defecation, before
preparing meals and before feeding children.
Protect children in malaria endemic areas, by ensuring that they sleep
under Insecticide - treated bed nets.
58 Provide appropriate care for HIV/AIDS affected people, especially
orphans, and Take action to prevent further HIV infections.
C - IMNCI: cont.…
Appropriate care at home:
Continue to feed and offer more fluids, including breast milk to
children when they are sick.
Appropriate home treatment for infections.
Protect children from injury and accident and provide treatment
Prevent child abuse and neglect, and take action when it does
Involve fathers in the care of their children and in the reproductive
health of the family.
Care-seeking outside the home:
Recognize when sick children need treatment outside the home and
seek care from appropriate providers.
Complete a full course of immunization before first birthday.
Follow the health provider’s advice on treatment, follow-up and
Ensure that every pregnant woman has adequate antenatal care,
Inadequacies in Health system:
Health worker skills:
Incomplete examinations and counselling.
Poor communication between health workers and parents.
Irrational use of drugs.
Health system issues:
- Access to health services and Scarce availability of Skilled
- Availability of appropriate drugs and vaccines
- Supervision / organization of work
Community and family practices:
Delayed care seeking
Poor knowledge of when to return to a health facility
Seeking assistance from unqualified providers
Poor adherence to health worker advice and treatment
Implementation of IMNCI in
As of December 2009, about 297 districts are
implementing this programme in India.
implemented in Raichur district as a pilot
project during 2005-06.
Till date 14 districts have been covered with
an objective to cover all the districts of the
state by 2011-12 in Karnataka.
Strengths of IMNCI
Evidence based management decisions.
Feasible to incorporate into both pre-service
training & in-service training.
Hands-on clinical training for 50% of training time.
Focus on communication & counselling skills.
Locally adapted recommendations for infant and
young child feeding.
Lowers the burden to hospitals.
Model to improve health care.
Challenges of IMNCI
Issues regard to safe home delivery.
A referral system with linkages between the
different health care systems.
Care of newborn at birth and childhood
Feasibility of provision of health care using
IMNCI at sub-center and village level by
ANMs and AWWs.
Irregular supply of drugs & logistics.
Lack of proper supervision.
Making home based care of young infants
operational by ANMs and AWWs and a high
1. Integrated management of neonatal and childhood illness. Modules 1 to 9.
Ministry of health & Family welfare, Government of India, New Delhi. 2009.
Student’s handbook for IMNCI. Ministry of health & Family welfare,
Government of India, New Delhi. 2007.
Facility based newborn care operational guide. Ministry of health & Family
welfare, Government of India, New Delhi. 2011.
Home based newborn care operational guidelines. Ministry of health &
Family welfare, Government of India, New Delhi. 2011.
Park K . Textbook of Preventive and Social Medicine. 21st ed. Jabalpur:
Bhanot; 2009. p. 414,530,550.
Current statistical data on IMR and U5MR from www.worldbank.org (data
2012-13) accessed on 20-12-2013 at 2:30 am.
Ingle GK, Malhotra C. Integrated management of neonatal and childhood
illness: An overview. IJCM 2007 Apr;32(2):108-110.