ppt for teaching purposes of medicine undergrads

1. Integrated Management of
Neonatal and Childhood Illness
(IMNCI)
1

2. Plan of presentation
 Background for IMCI
 Rationale for IMNCI
 IMNCI



2

- Guidelines
- Components
- Principles of Integrated care
- Elements of case management process
- Case management process chart book
F-IMNCI
Implementation of IMNCI
Critical review
References

3. Introduction
•
IMR Of the world
34.9deaths/1000 live births
India
43.8deaths/1000 live
births
• U5MR Of the world
47.8deaths/1000 live births
India
56.3deaths/1000 live
births
• Reduce infant and child mortality rates
• Improving child health & survival
• IMR reduced from 114 (1980) to 47 (2010 SRS
3
bulletin) and now as above.

4. Background of IMCI
 Every year more than 10 million children die in
developing countries before they reach their fifth
birthday.
 7 in 10 of these deaths are due to five preventable
and treatable conditions.
 Pneumonia,
diarrhoea,
malaria,
measles
and
malnutrition – and often to a combination of these
4
conditions.

5. Causes of Child deaths
5

6. Background of IMCI (Contd…)
The 5 main killers of
children:
ARI, diarrhoea,
measles, malaria
and malnutrition
 In India, common illnesses in children under 3
years of age include fever (27%), acute
respiratory infections (17%), diarrhoea (13%)
and
malnutrition
(43%)
and
often
in
combination.*
 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
control them.**
 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.
1990
55%
Perinatal
conditions
Other
communicable
diseases
Non-communicable
diseases
Injuries
19%
12%

7. Infant mortality trend in India
7

8. Neonatal mortality in India
8

9. IMR and MDG
9

10. Rationale for an integrated evidence
based syndromic approach to case
management
 Many well-known prevention and treatment strategies have




10
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

11. 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.
 Ensures
illnesses.
11
appropriate combined treatment of all

12. Key features of IMCI (Contd. . .)
 Strengthens the counseling of caretakers.
 Speeds up the referral of severely ill children.
 Promotes
appropriate care seeking behaviors,
improved nutrition & preventive care & correct
implementation of prescribed care.
 Provision of home based newborn care to
1.
promote exclusive breastfeeding
2.
prevent hypothermia
12 3.
improve illness recognition & timely care seeking

13. IMNCI- India
Home visits for young infants:
Schedule
 All newborns: 3 visits (within 24 hours of birth, day 3-4 and
day 7-10)
 Newborns with low birth weight: 3 more visits on day 14, 21
and 28.
13

14. IMCI Process:
Source: IMCI; Student’s Handbook, WHO

15. IMNCI- India
 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.
15
 Skill based.

16. Difference between IMCI and IMNCI
Features:
WHO – UNICEF IMCI
IMNCI
Coverage of 0 to 6 days (early
newborn period)
No
Yes
Basic Health Care Module
NO
Yes
Home visit by the provider for
newborn and Young Infant
No
Yes
Training
Training Home based Care
No
Training days for newborn and 2 out of 11 days
young infants
Sequence of training
Yes
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.)

17. 17

18. Up to 50%
of neonatal
deaths are in
the first 24 hours
75% of neonatal
deaths are in
the first week –
3 million deaths
18
Time
when most babies die is
when coverage
of care is lowest

19. Guidelines for IMNCI
 Evidence-based, syndromic approach to case
19
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
patients.

20. 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.
20

21. 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.
i.
21

22. 22

23. 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
symptom “diarrhoea”.
 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.
23

24. 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
24

25. 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
25
active participation of caretakers in the treatment of

26. IMNCI is a Key Strategy for Improving Child
Health
By integration
Management
of sick
children
Nutrition
Integrated Management
of Childhood Illness
Immunization
Other disease
prevention
Promotion of
growth and
development

27. Elements of case management
process
 Assess
- 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.
27
 Follow up care - Reassess the child for new problems.

28. The case management process…
28

29. IMCI case management at first level health facility,
referral level, and home :
29

30. Integrated Case Management Process
for the sick young infant up to 2
months of age
30

31. Assess , classify and treat the sick young infant up to 2
months
31

32. Look … listen… feel…
32

33. Assess and classify young infant for
diarrhoea
33

34. Feeding problem and malnutrition chart
34

35. Treatment of sick young infants
35

36. 36

37. 37

38. Counseling a mother or caretaker
 Ask and Listen
 Praise
 Advice
 Check
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
38
 Counsel the mother about her own health

39. Mother’s card
39

40. Prescription slip
40

41. Integrated Case Management Process of
children age 2 months up to 5 years
41

42. 42

43. 43

44. Cough or difficult breathing
44

45. Diarrhoea
45

46. Malaria & Measles
46

47. Ear problem chart
47

48. Malnutrition chart
48

49. 49

50. Anaemia chart
50

51. Treatment procedures for sick children
51

52. 52

53. 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.
53
* Bulletin on Rural Health Statistics

54. F-IMNCI
 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

55. Components of F-IMNCI
 Skill based training
 Improvements to the health system :
Logistics/Manpower/ Referral mechanisms
 Improvement of Family and Community Practices
55

56. Institutional arrangements
 State level
 District level
 Trainee:
 Trainers:
 Training of trainers:
 Number to be trained:
 Training institutions:
 Funding :
56

57. C - IMNCI: Community and Household
IMNCI:
 Community IMNCI is basically Component 3 of the
IMCI Package.
 It aims at improving family and community practices
by promoting those Practices with the greatest
potential for improving child survival, growth and
development.
 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.
57

58. 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
longer.
 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
environment.
Disease prevention:
 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.

59. 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
when necessary.
 Prevent child abuse and neglect, and take action when it does
occur.

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
59 referral.

Ensure that every pregnant woman has adequate antenatal care,

60. 60

61. 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
Worker
- 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

62. Implementation of IMNCI in
India/Karnataka
 As of December 2009, about 297 districts are
implementing this programme in India.
 In
Karnataka,
IMNCI
programme
is
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.
62

63. 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.
 Cost effective.
 Lowers the burden to hospitals.
 Model to improve health care.
63

64. Challenges of IMNCI
 Issues regard to safe home delivery.
 A referral system with linkages between the





64
different health care systems.
Care of newborn at birth and childhood
injuries.
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

65. References
1. Integrated management of neonatal and childhood illness. Modules 1 to 9.
2.
3.
4.
5.
6.
7.
65
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.

66. 66

67. IMNCI
…In an effort to meet Millennium
Goals
67