Distribution of deaths of children less than 5 Years, by cause, the world, 1990 and projected for 2020The 5 main killers ofchildren: 1990 2020ARI, diarrhoea,measles, malariaand malnutrition 55% 52%PerinatalconditionsOther 5% 7%communicable 9% 18%diseases 19% 12% 11%Non-communicable 11%diseasesInjuries
For many sick children a singlediagnosis 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 3311 Infectious and Parasitic diseases Ill defined Injuries 14 Nutritional def 22 Malaria Cong. Anamolies PUO
Share of under-five mortality in IndiaNeonatal 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 healthManagement Nutrition Immunization Other diseaseof 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 ProcessTwo 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
Standard Clinical Guidelines “Golden” paediatric standard Completeexamination 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 ChildTools 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 andRefer 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 movemento Umbilicus red or draining pus or LOCAL BACTERIALo Pus discharge from ear or INFECTIONo < 10 skin pustules
VIDEO• GRUNTING- Short expiratory sound, signifies infant having difficulty in breathing- Severe illness• 2 Grunting.wmv
VIDEOSIGNS 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 CLASSIFICATIONSSick Young Infant age up Sick Child age 2 months upto 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 fortreating 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.