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  1. 1. Integrated Management of Neonatal and Childhood Illnesses Dr Manish Chandra Prabhakar Mahatma Gandhi Institute of Medical Sciences Sewagaram Wardha, Maharashtra, India
  2. 2. WHY AGAIN
  3. 3. NOW IS THE TIME TO PUT TO USE WHATEVER YOU HAVE LEARNT One who is not able to apply whatever he has learnt is no better than who has not learnt at all.
  4. 4. The Evidence • file://localhost/Users/abhishekvraut/Deskto p/bmj.pdf
  5. 5. Evaluation of IMNCI Aim: To generate evidence of impact on mortality, necessary for continued and increased investment for scale-up Primary objective: To determine the effectiveness of implementing the IMNCI strategy on a district-wide scale in reducing neonatal and infant mortality Secondary objectives: To determine the effect of IMNCI on - newborn and infant care practices - prevalence of neonatal and infant illness - care seeking for illness
  6. 6. Study Design  Cluster randomized effectiveness trial in district Faridabad, Haryana, with a population of ~1.1 million  Random allocation of 18 clusters (Primary Health Centre areas) to intervention or control, after a baseline survey
  7. 7. Study Site  Primarily rural setting  Schooling (median years): men 9, women 3  62% population uses open fields for defecation  Over half the deliveries occur at home Health care system  Village level: AWW, ASHA  Health sub-centre: ANM  Primary health centre: Physicians  Private practitioners within or near village most common source of child health care (~ 60%)
  8. 8. Sample Size 33,000 births per group; sufficient to detect a difference between the intervention and control groups of:  18% in Infant Mortality  20% in Neonatal Mortality Assumptions: - IMR 60 per 1000; NMR 40 per 1000 (baseline survey) - 80% power - 95% confidence - inter cluster coefficient of variation (k) of 0.11 - 10% attrition
  9. 9. The intervention Put in place: Jan-Dec 2007 Improving CHW skills to promote newborn care practices Improving Case Management Skills of CHW and HW Strengthening Health System to Implement IMNCI - Supervision of CHW/HW - Task-based incentives for IMNCI activities - Ensuring supply of medicines
  10. 10. Home visits for newborn care by AWW
  11. 11. Treatment close to homes by ASHA
  12. 12. Women's group meetings by ASHA
  13. 13. Supportive supervision
  14. 14. Medicine depots at home of ASHA
  15. 15. Statistical Analysis Intention to Treat Analysis  Pregnancy identified through surveillance, outcome live birth or stillbirth  Vital status known at least for the neonatal period  Subgroup analysis: above, plus born at home  Cluster-level analysis, weighted for births in cluster  Comparison using Poisson regression models  Rate ratios adjusted for two important differences in baseline survey: distance from the highway and proportion of health facility births
  16. 16. Summary of key Findings
  17. 17. Intervention Coverage  Home visits: 90% newborns visited; but only 43% visited thrice and 57% within the first 2 days  Women's group meetings: 45% caregivers attended a meeting  Case management: 60-80% of sick newborns and children sought treatment; but only half of them from an appropriate provider
  18. 18. Newborn Care Practices improved 90% 84.5% 80% 84.1% 77.6% 70% 60% 50% 46.2% 40.7% 40% 39.5% 37.3% Control 30% 20% 11.2% 10% 0% Initiation breastfeeding within one hour of birth EBF at 4 weeks of age Intervention Delayed bathing Nothing or GV paint applied on cord
  19. 19. Reduced morbidity and improved care seeking * Morbidity 2 weeks preceding 6 months interview ** Care seeking within 24 hours from an appropriate provider 45% 39.7% 40% 35% 30% 28.4% 25% 23.5% 20.6% 21.3% 20.8% Intervention 20% Control 16.3% 14.5% 15% 12.3% 10% 10.1% 8.8% 7.8% 5% 0% Severe morbidity Diarrhoea at 6 Pneumonia at 6 in neonatal period months interview months interview (22% lower) (32% lower)* (33% lower) Care seeking for severe newborn illness** Care seeking for diarrhoea at 6 months** Care seeking for pneumonia at 6 months**
  20. 20. Impact on Mortality  13% (CI 1-23%) reduction in neonatal, 18% (CI 11-35%) reduction in infant mortality  19% (CI 5 to 31%) and 24% (CI 1432%) reductions in neonatal and infant mortality in sub-group of home births
  21. 21. Important strengths of the Study  Large cluster-randomized controlled trial in over a million population to evaluate a complex child survival intervention  Effectiveness design, intervention delivery within the health system  IMNCI operationalized in a realistic manner open to innovation, and possible to scale up  Separate evaluation team; identical system in intervention and control clusters
  22. 22. Limitations  Relatively few clusters: clusters large, PHC area unit of randomization to avoid contamination  Some cluster level baseline differences despite stratified randomization: Results adjusted for baseline differences  Some aspects of the intervention beyond routine IMNCI implementation in India: additional aspects realistic and possible to scale up
  23. 23. ★ Implications • Comprehensive, integrated strategies such as IMNCI are feasible to deliver and improve newborn and infant survival. • This strategic approach should be scaled up to help achieve MDG4 in India and other developing countries. • To maintain and increase impact beyond that in the trial: – Quality training, adequate supervision, timely supplies, and taskbased CHW incentives are critical – Proportion of early postnatal visits can be increased by adding home visits during pregnancy to IMNCI design – Access to referral care can be increased by improving links of community and health facility with district and sub-district hospitals
  24. 24. IMNCI
  25. 25. 4 million newborn deaths - When? Up to 50% of neonatal deaths are in the first 24 hours 75% of neonatal deaths are in the first week – 3 million deaths
  26. 26. 4 million newborn deaths Where? • Two-thirds of deaths are in 10 countries • Largest numbers of deaths are in South Asia • Highest rates of death are in Africa • Rates are higher for the poor
  27. 27. Causes of Child deaths
  28. 28. ★ Future Scenario : Underfive Mortality Global distribution of deaths of children less than 5 Years By cause,1990 and projected for 2020 The 5 main killers of children: ARI, diarrhoea, measles, malaria and malnutrition 1990 2020 55% 52% Perinatal conditions Other communicable diseases Non-communicable diseases 19% 5% 9% 7% 18% 11% 12% 11% Injuries Department of Child and Adolescent Health and Development. World health Organization
  29. 29. ★ Global trends in under-five mortality Under-five mortality per 1000 200 There is a need to find new ways to expand coverage of available and effective interventions 175 150 125 If recent trends continue 100 75 50 To achieve MDG 25 0 60 65 70 75 80 85 90 95 00 05 10 15 Source: Data from Ahmad OB, Lopez AD & Inoue M. The decline in child mortality: a reappraisal. Bull WHO, 2000, 70(10), with trend extended through 2015 (in red) and linear trend needed to achieve 2/3 reduction from 1990 levels.
  30. 30. 4 million newborn deaths a year: almost 40% of under-5 child deaths Millennium Development Goal 4: reduce child mortality by two-thirds from 1990 to 2015 Can only be achieved if we reduce neonatal deaths -- missing from current programmes
  31. 31. Need for IMNCI For optimum utilization of our limited resources….. ….. Prioritization of interventions is critical to respond to common public health issues….
  32. 32. IMNCI components • IMNCI has three interdependent components: – Improving Health Worker Skills – Training in case management skills. – Improving Health Systems – Ensuring a functioning health service and adequate drug supply. – Improving Family and Community Practices – Developing community awareness about prevention and treatment of common illnesses.
  33. 33.
  34. 34. IMNCI strategy Newborn 1-7d Immunization Diarrhea IMNCI BF-CF ARI Fever/ malaria
  35. 35. IMNCI Strategy is based on these time tested interventions but not a combination of interventions Management of diarrhoea ORT Management of ARI ARI Control Immunization EPI/ UIP Nutrition NP
  36. 36. 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
  37. 37. IMNCI Strategy Integration of components Integrated clinical assessment and treatment Knowledge and behaviours of caretakers Capacity, structure and functions of the health system
  38. 38. Goals of IMNCI • Standardized case management of sick newborns and children • Focus on the most common causes of mortality • Nutrition assessment and counselling for all sick infants and children • Home care for newborns to – promote exclusive breastfeeding – prevent hypothermia – improve illness recognition & timely care seeking
  39. 39. Newborn care – – – – – Pregnancy care Skilled care at birth Care for newborns with complications Parenting skills and care in the home Bridging the handover between maternal and child health services
  40. 40. Steps in Management (a) Assess the child for group of symptoms (b) Classify the severity of disease (c) Treat as per the laid out plan (d) Counsel the mother (e) Follow up care Age Categories (a) Young infants (age up to 2 months) (b) Children (2 months up to 5 years)
  41. 41. ★ file://localhost/Users/abhishekvraut/Desktop/2 months.pdf
  42. 42. ★ 2-5 yrs.pdf
  43. 43. ★ BACTERIAL INFECTION POSSIBLE SERIOUS BACTERIAL INFECTION Convulsions or Fast breathing (60 breaths per minute or more) or Severe chest indrawing or Nasal flaring or Grunting or Bulging fontanelle or 10 or more skin pustules or a big boil or If axillary temperature 37.5C or above (or feels hot to touch) or temperature less than 35. 5 C (or feels cold to touch)) or Lethargy or unconsciousness or Less than normal movement LOCAL BACTERIAL INFECTION Umbilicus red or draining pus or Pus discharge from the ear or < 10 skin pustules.
  44. 44. ★ Jaundice SEVERE JAUNDICE Yellow Palms and soles or Age <24 hours Age 14 days or more JAUNDICE Palms and soles not yellow and Age 1-13 days
  45. 45. ★ Pneumonia SEVERE PNEUMONIA OR VERY SEVERE DISEASE Any general danger sign or Chest indrawing or Stridor in calm child PNEUMONIA Fast breathing NO PNEUMONIA: COUGH OR COLD No signs of pneumonia or very severe disease
  46. 46. ★ Temperature LOW BODY TEMPERATURE Temperature between 35.5- 36.4 C
  47. 47. ★ Diarrhoea SEVERE DEHYDRATION Two of the following signs: Lethargic or unconscious Sunken eyes Skin pinch goes back very slowly SOME DEHYDRATION Two of the following signs: Restless, irritable Sunken eyes Skin pinch goes back slowly NO DEHYDRATION Not enough signs to classify as some or severe dehydration • SEVERE PERSISTENT DIARRHOEA • SEVERE DYSENTERY
  48. 48. ★ Feeding problems NOT ABLE TO FEED – POSSIBLE SERIOUS BACTERIAL INFECTION OR SEVERE MALNUTRITION Not able to feed or No attachment at all or Not suckling at all or Very low weight for age FEEDING PROBLEM OR LOW WEIGHT Not well attached to breast or Not suckling effectively or Less than 8 breastfeeds in 24 hours or Receiving other foods or drinks or Thrush (ulcers or white patches in mouth) Low weight for age Breast or nipple problems
  49. 49. ★ Anemia SEVERE ANAEMIA Severe palmar pallor ANAEMIA Some palmar pallor NO ANAEMIA No palmar pallor
  50. 50. 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.
  51. 51. F - IMNCI
  52. 52. Why Facility based-IMNCI ? • Child Health-Approach under RCH-II stated that : A component on the management of sick neonates and children in the inpatient setting at PHCs, CHCs FRUs be added. Health system strengthening be addressed effectively to ensure effective implementation IMNCI does not offer facility care
  53. 53. Ensuring continuum and quality of care Facility based Inpatient management Outpatient IMNCI Community Home visits by AWW/ASHA
  54. 54. Components of Facility based part of FIMNCI Emergency triage and treatment for children brought to facility Care at Birth & postnatal care for neonates born at the facility Facility based care of sick young infants Facility based management of Sick Children Management Of Severe Acute Malnutrition
  55. 55. ★ Process
  56. 56. ★ Triage of all sick children
  57. 57. ★ Priority signs
  58. 58. Full spectrum of IMNCI Duration Newborns Older Children Facility Care at Birth Triage Based Care + + = 5 days In-patient In-patient IMNCI Out-patient Out-patient = 6 days + referral + referral
  59. 59. Students' Handbook and Teachers' Guide/IMNCI Students' Handbook.pdf and Manuals/Facility based IMNCI/F-IMNCI Chart booklet/F-IMNCI chart booklet.pdf Facility_based_care_chartbooklet.pdf file://localhost/Users/abhishekvraut/Desktop/IMNCI Students' Handbook.pdf
  60. 60. IMNCI Efforts to meet Millennium Goals
  61. 61. Be Responsible…… ………. and cheerfully do the best ‘U’ can