Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Imnci

644 views

Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Imnci

  1. 1. IMNCI Nebiyu A.
  2. 2. Introduction • Since the 1970s, the estimated annual number of deaths among children less than 5 years old has decreased by almost a third. • This reduction, however, has been very uneven. And in some countries rates of childhood mortality are increasing. • Every minute 20 children under 5 years of age die, leading to 10.6 million deaths each year. • Altogether more than 10 million children die each year in developing countries before they reach their fifth birthday
  3. 3. contd.. The majority of these deaths are caused by conditions that are either preventable or treatable, Seven in ten of these deaths are due to: • acute respiratory infections (mostly pneumonia) • diarrhea • measles • malaria • malnutrition • and often to a combination of these conditions
  4. 4. contd..
  5. 5. In Ethiopia Each year an estimated 472,000 children under the age of five die in Ethiopia, placing Ethiopia sixth in the world in terms of absolute number of under-5 deaths. The proportions of attributable causes of under-5 mortality have been estimated as follows: • pneumonia 28% • neonatal complications 25% • malaria 20% • diarrhea 20% • measles 4% • AIDS 1% and • other 2%
  6. 6. • In some countries, three in four episodes of childhood illness are caused by one of these five conditions • At this level, in most developing countries, diagnostic supports such as radiology and laboratory services are minimal or non-existent; and drugs and equipment are scarce. • Limited supplies and equipment • combined with an irregular flow of patients, leave health care providers at first-level facilities with few opportunities to practice complicated clinical procedures
  7. 7. • Providing quality care to sick children in these conditions is a serious challenge. • In response to this challenge, WHO and UNICEF developed a strategy known as Integrated Management of Childhood Illness (IMCI). • Although the major stimulus for IMCI came from the needs of curative care, • The strategy combines improved management of childhood illness with aspects of nutrition, immunization, and other important disease prevention and health promotion elements. • The objectives are to reduce deaths and the frequency and severity of illness and disability and to contribute to improved growth and development.
  8. 8. • Since 2006, the newly adapted version has incorporated care and management of newborns below the age of 7 days of life and its name has been changed to IMNCI, Integrated Management of Newborn and Childhood Illness. • Currently, HIV/AIDS is a major public health problem in many African countries especially in the Sub-Saharan Region. • Thus, HIV/AIDS is adapted into the Ethiopian IMNCI algorithm taking into consideration the increasing magnitude of childhood HIV/AIDS in the country
  9. 9. • It is a case management process for a first-level facility such as a clinic, a health centre or an outpatient department of a hospital
  10. 10. The strategy includes three main components • Improvements in the case-management skills of health staff through the provision of locally adapted guidelines on IMNCI and through activities to promote their use • Improvements in the health system required for effective management of childhood illness • Improvements in family and community practices
  11. 11. • The clinical guidelines – They promote evidence-based assessment and management, using a syndromic approach that supports the rational, effective and affordable use of drugs. – They include methods for assessing signs that indicate severe disease; – assessing a child's nutrition, immunization, and feeding; – teaching parents how to care for a child at home; – counseling parents to solve feeding problems; and advising parents about when to return to a health facility
  12. 12. – The guidelines also include recommendations for checking the parents' understanding of the advice given and for showing them how to administer the first dose of treatment.
  13. 13. Principles of integrated case management • All U5s first checked for signs of severe illness – General Danger Signs – Signs of Very Severe Disease • All children assessed for main symptoms, Malnutrition and anemia, HIV, immunizations, de-worming, and other problems • Limited number of clinical signs used • Color-coded Classification system for easy triaging • Limited number of Essential drugs needed • Emphasis on Counseling & active participation of care- givers on - Home care & Feeding and fluids - When to return (immediately or for F/up) • Well-defined Follow-up care
  14. 14. Steps in integrated case management 1. ASSESS - Good communication skills - Focused assessment 2. CLASSIFY – using a combination of signs 3. IDENTIFY TREATMENT & TREAT eg. Pre-referral Rx, first dose of oral drugs, advice 4. COUNSEL 5. FOLLOW-UP urgent pre-referral treatment and referral, or specific medical treatment and advice, or simple advice on home management
  15. 15. IMNCI Case MaNageMeNt steps Sick Children (age 2 months up to 5 years)
  16. 16. IMNCI Case MaNageMeNt steps Age 2 months up to 5 years General Danger Signs Main Symptoms Cough or Difficult Breathing Diarrhoea Fever Ear Problems Nutritional Status HIV/AIDS Immunization Status Other Problems
  17. 17. General Danger Signs DANGER SIGNS CONVULSIONS INABILITY TO DRINK OR BREASTFEED VOMITING LETHARGY UNCONSCIOUSNESS
  18. 18. Cough or difficult breathing Ask: – Cough, or – Difficult breathing (ask or look) Look, listen, feel: – General Danger Signs – Breathing Rate – Chest In-drawing – Stridor If the child is: The child has fast breathing if you count: 2 months up to 12 months: 12 months up to 5 years: 50 breaths per minute or more 40 breaths per minute or more.
  19. 19. Classification of cough/difficult breathing SIGNS CLASSIFY AS TREATMENT (Urgent pre-referral treatments are in bold print) • Any general danger sign or •Chest indrawing or •Stridor in calm child SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of Cotrimoxazole* Refer URGENTLY to hospital** •Fast breathing PNEUMONIA Give Cotrimoxazole for 5 days Soothe the throat and relieve the cough with a safe remedy Advise mother when to return immediately Follow-up in 2 days •No signs of pneumonia or very severe disease NO PNEUMONIA COUGH OR COLD If coughing more than 21 days, refer for assessment Soothe the throat and relieve the cough with a safe remedy Advise mother when to return immediately. Follow-up in 5 days if not improving
  20. 20. Assessment of Diarrhea • Ask: - Duration? - Blood in the stool? • Look, Listen, Feel • Sensorium (lethargic OR restless) • Sunken Eyes (ask caretaker as well) • Drinking (poorly OR eagerly) • Skin Pinch (very slowly OR slowly OR immediately)
  21. 21. Classification of dehydration Two of the following signs: Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly SEVERE DEHYDRATION If child has no other severe classification: - Give fluid for severe dehydration (Plan C). OR If child also has another severe classification: Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. If child is 2 years or older, and there is cholera in your area, give antibiotic for cholera Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly SOME DEHYDRATION Give fluid, Zinc supplements and food for some dehydration (Plan B) If Child also has a severe classification: - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. Advise mother when to return immediately. Follow-up in 5 days if not improving If confirmed/suspected symptomatic HIV, follow-up in 2 days if not improving Not enough signs to classify as some or severe dehydration NO DEHYDRATION Give fluid, Zinc supplements and food to treat diarrhoea at home (Plan A) Advise mother when to return immediately. Follow-up in 5 days if not improving. If confirmed/suspected symptomatic HIV, follow-up in 2 days if not improving
  22. 22. Persistent diarrhea and Dysentery  Dehydration present SEVERE PERSISTENT DIARRHOEA Treat dehydration before referral unless the child has another severe classification. Give Vitamin A. Refer to hospital.  No dehydration PERSISTENT DIARRHOEA Advise the mother on feeding a child who has PERSISTENT DIARRHOEA. Give Vitamin A, therapeutic dose. Advise mother when to return immediately. Follow-up in 5 days.  Blood in the stool DYSENTRY  Treat for 5 days with Cotrimoxazole.  Advise mother when to return immediately.  Follow-up in 2 days.
  23. 23. Fever • Fever associated with malaria, is the main focus of IMNCI Guidelines • Important to determine the malaria risk based on altitude, season & travel history – In high risk areas, all children with febrile diseases assumed to have malaria – In low risk areas, only children with no other diagnoses should be considered to have malaria – In no risk areas, anti-malarials should not be used
  24. 24. Assessment of Fever • ASK – For how long has the child had fever? – If more than 7 days, has fever been present every day? – Has the child had measles within the last 3 months? • LOOK AND FEEL: – Look or feel for stiff neck – Look or feel for bulging fontanels (< 1year old) – Look for runny nose – Look for signs of MEASLES • Generalized rash and one of these: cough, runny nose, or red eyes
  25. 25. Any general dangers sign or Stiff neck or Bulging fontanels VERY SEVERE FEBRILE DISEASE •Give Quinine for severe malaria (first dose). •Give first does of Chloamphenicol. •Treat the child to prevent low blood sugar. •Give one dose of Paracetamol in clinic for high fever (38.50 C or above). •Refer URGENTLY to hospital. Positive blood film/RDT or If blood film/RDT not available Fever (by history or feels hot or temperature 37.50 C or above). MALARIA Treat with Coartem Give one dose of Paracetamol in clinic for high fever (38.50 C or above). Advise mother when to return immediately. Follow-up in 2 days if fever persists. If fever is present every day for more than 7 days, refer for assessment. Any general danger sign or Stiff neck or Bulging fontanels VERY SEVERE FEBRILE DISEASE •Give Quinine for severe malaria (first dose) •Give first dose of Chloamphenicol •Treat the child to prevent low blood sugar. •Give one dose of Paracetamol in clinic for high fever (38.50 C or above) •Refer URGENTLY to hospital •Positive blood film/RDT or •If blood film/RDT not available •NO runny nose and •NO measles and •NO other causes of fever. MALARIA Treat with Coartem. Give one dose of Paracetamol in clinic for high fever (38.50 C or above) Advise mother when to return immediately. Follow-up in 2 days if fever persists. If fever is present every day for more than 7 days, refer for assessment. Blood film/RDT negative or If blood film/RDT not available: Runny nose PRESENT or Measles PRESENT or Other causes of fever PRESENT FEVER MALARIA UNLIKELY Give one dose Paracetamol in clinic for high fever (38.50 C or above) Treat other obvious causes of fever Advise mother when to return immediately Follow-up in 2 days if fever persists. If fever is present every day for more than 7 days, refer for assessment. Any general danger sign or Stiff neck or Bulging fontanels VERY SEVERE FEBRILE DISEASE Give first dose of Chloamphenicol. Treat child to prevent low blood sugar Give one dose of Paracetamol for high fever (38.50 C or above) Refer URGENTLY to hospital Any fever FEVER (NO MALARIA) Give one dose of Paracetamol for high fever (38.50 C or above) Treat other obvious causes of fever Follow-up in 2 days if fever persists If fever is present every day for more than 7 days, refer for assessment No Malaria Risk Low Malaria Risk High Malaria Risk Classify FEVER
  26. 26. MEASLES • If the child has measles now or within the last 3 months: –Look for mouth ulcers • Are they deep and extensive? –Look for pus draining from the eye. –Look for clouding of the cornea.
  27. 27. Classification of measles Any general danger sign or Clouding of cornea or Deep or extensive mouth ulcers SEVERE COMPLICATED MEASLES  Give Vitamin A, first dose  Give first dose of Chloramphenicol  If clouding of the cornea or pus draining from the eye, apply Tetracycline eye ointment.  Refer URGENTLY to hospital Pus draining from the eye, or Mouth ulcers MEASLES WITH EYE OR MOUTH COMPLICATIONS  Give Vitamin A, therapeutic dose  If pus draining from the eye, treat eye infection with Tetracycline eye ointment.  If mouth ulcers, treat with gentian violet  Advise mother when to return immediately  Follow-up in 2 days •Measles now or within the last 3 months MEASLES  Give Vitamin A, therapeutic dose  Advise mother when to return immediately
  28. 28. Assessm. & classification of Ear problem IF YES, ASK: • Is there ear pain? • Is there ear discharge? - If yes, for how long? LOOK AND FEEL: • Look for pus draining from the ear • Feel for tender swelling behind the ear  Tender swelling behind the ear MASTOIDITIS Give first dose of Cotrimoxazole Give first dose of Paracetamol for pain Refer URGENTLY to hospital  Pus is seen draining from the ear and discharge is reported for less than 14 days or  Ear pain ACUTE EAR INFECTION Give Cotrimoxazole for 5 days Give Paracetamol for pain Dry the ear by wicking Follow-up in 5 days  Pus seen draining from the ear and discharge is reported for 14 days or more CHRONIC EAR INFECTION Dry the ear by wicking Treat with Topical Quinolone ear drops for 2 weeks Follow-up in 5 days  No ear pain and  No pus seen draining from the ear NO EAR INFECTION No additional treatment
  29. 29. Nutritional Status & Anemia MALNUTRITION  For all children Look for edema of both feet & Determine weight for age  For children up to six months - Look for visible severe wasting  For children aged 6 months or more( Lt/Ht 65-110 cm) - Determine if MUAC is less than 11.0 cm  Assess appetite (if MUAC < 11.0 cm or edema of both feet & no medical complications) ANAEMIA - Look for palmar pallor, is it; - Severe palmar pallor? - Some palmar pallor?
  30. 30. • If age up to 6 months - and visible severe wasting or - edema of both feet • If age 6 months and above & - MUAC < 11 cm (Lt 65 - 110cm), or edema of both feet - and fail appetite test, or has pneumonia/persistent diarrhea/dysentery/measles...  SEVERE COMPLICATED MALNUTRITION   Treat the child to prevent low blood sugar    Give first dose of Vitamin A for all except for those with edema or those who received a dose in the past 6 months    Refer URGENTLY to hospital  • If age 6 months or above and - MUAC < 11 cm (Lt = 65 - 110cm), or edema of both feet And - pass appetite test, and - no medical complications   SEVERE UNCOMPLICATED MALNUTRITION  Refer to the Outpatient Treatment Program (OTP) When OTP is not available, manage as follows:-  Give RUTF (see page 70) and counsel the mother on how to feed a child with RUTF, if available, or else refer to hospital  Give first dose of Vitamin A (as above)  Give amoxicillin for 7 days  Give single dose of 5mg folic acid for those with anemia  Give Mebendazole (if child aged one year or above),  Advise the mother when to return immediately  Follow-up in 7 days   • Very low weight for age VERY LOW WEIGHT  Assess the child’s feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart - If feeding problem, follow-up in 5 days   Advise mother when to return immediately.  Follow-up in 30 days.   • Not very low weight for age and no other signs   NOT VERY LOW WEIGHT  If child is less than 2 years old, assess the child’s feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart. - If feeding problem, follow-up in 5 days   Advise mother when to return immediately
  31. 31. Classification of Anemia  Severe palmar pallor SEVERE ANAEMIA  Refer URGENTLY to hospital  Some palmar pallor ANAEMIA  Assess the child’s feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart.  Give iron  Give oral antimalarial if high malaria risk.  Give Mebendazole or Albendazole if child is 12 months or older and has not had a dose in the previous 6 months.  Advise mother when to return immediately.  Follow-up in 14 days.  No palmar pallor NO ANAEMIA  No additional treatment
  32. 32. Assessment for HIV infection Check for HIV infection:  If the mother or child has a positive HIV test or  If the child has one or more of the following classifications now: • Pneumonia or severe pneumonia • Persistent diarrhoea or severe persistent diarrhoea • Acute ear infection with discharge, or chronic ear infection • Very low weight or severe malnutrition NOTE OR ASK: • Is the mother known to have a positive HIV test? • Is the child known to have a positive HIV test? • Does the child have PNEUMONIA or SEVERE PNEUMONIA / VERY SEVERE DISEASE now? • Does the child have PERSISTENT / SEVERE PERSISTENT DIARRHOEA now? • Does the child have EAR DISCHARGE now? • Does the child have VERY LOW WEIGHT / SEVERE MALNUTRITION? LOOK AND FEEL: • Oral thrush • Bilateral Parotid enlargement for 14 days or more • Enlarged lymph node in two or more sites: neck, axilla, or groin
  33. 33. Classification of HIV infection Positive HIV antibody test in a child 18 months and above, OR, Positive PCR test at any age AND Two or more of the following HIV - related conditions:  Pneumonia/Severe Pneumonia Persistent diarrhoea/severe persistent diarrhoea Ear discharge Very low weight/Severe Malnutrition Oral thrush Enlarged palpable lymph nodes in two or more sites Bilateral parotid enlargement for 14 days or more CONFIRMED SYMPTOMATIC HIV INFECTION Give Cotrimoxazole Prophylaxis Treat HIV-related conditions if present (eg., thrush) Give multivitamin supplements Assess the child's’ feeding and counsel as necessary Counsel the mother about her own HIV status and arrange counselling and testing if necessary Advise the mother on home care Refer for ARV Positive HIV antibody test in a child 18 months and above, OR, Positive PCR test at any age AND Less than two HIV- related conditions CONFIRMED HIV INFECTION Give Cotrimoxazole prophylaxis Treat HIV-related conditions if present (eg., thrush) Give multivitamin supplements Assess child’s feeding and counsel as necessary Advise the mother on home care Counsel the mother about her own HIV status and arrange counselling and testing if necessary Refer for ARV Positive HIV antibody test in a child under 18 months, OR, No HIV test result in a child AND  Two or more HIV-related conditions SUSPECTED SYMPTOMATIC HIV INFECTION Give Cotrimoxazole prophylaxis Treat HIV-related conditions if present (eg., thrush) Give multivitamin supplements Assess the child's’ feeding and counsel as necessary Advise on benefits of HIV test and refer for VCT ( mother &child) Advise the mother on home care Follow up in 14 days Positive HIV antibody test in a child under 18 months, OR Mother HIV Positive POSSIBLE HIV INFECTION or (HIV EXPOSED) Give appropriate feeding advice Treat HIV-related conditions if present (eg., thrush) Give Cotrimoxazole Prophylaxis and test for HIV at 18 months (If child still breastfed repeat HIV testing 3 months after stopping BF) Assess child’s feeding and counsel as necessary Follow-up in 14 days Negative HIV test in mother or child AND not enough signs to classify as suspected symptomatic HIV infn. HIV INFECTION UNLIKELY Treat, counsel and follow-up existing infections  Advise the mother about feeding and about her own health
  34. 34. Young Infants (Birth up to 2 months) IMNCI Case MaNageMeNt steps
  35. 35. IMNCI assessment steps, age birth up to 2 months Young Infants Birth Asphyxia Prematurity and low birth weight Possible serious bacterial infection & jaundice Diarrhea HIV Infection Feeding Problem or Low Weight Immunization Status Assess other problems
  36. 36. Newborn care during first week (0-6 days) • Essential Newborn Care at birth – Drying/covering & Assm of breathing/color – early skin-skin contact and BF – Cord & eye Care; Vitamin K • Assm & Management of Birth Asphyxia • Assm & Management of Prematurity and LBW – Feeding & Temperature Mx (Kangaroo Mother Care)
  37. 37. CHECK FOR POSSIBLE BACTERIAL INFECTION AND JAUNDICE LOOK, LISTEN, FEEL:  Count RR and look for severe chest indrawing.  Look and listen for grunting  Look for feel for bulging fontanelle  See if the infant is not feeding ;or is convulsing now  Measure temperature (or feel for fever or low body temp.)  Look at the umbilicus & for skin pustules.  Look at the young infant’s movements - Are they less than normal?  Look for Jaundice: Are the palms and soles yellow? Are skin on the face or eyes yellow? ASK  Has the infant had convulsions?  Is the infant not feeding ?
  38. 38. Classification of Possible serious bacterial infection SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print) • Not feeding well or • Convulsions/convulsing now or • Fast breathing (60 breaths per minute or more) or • Severe chest indrawing or • Grunting or • Fever (37.5°C* or above or feels hot) or • Low body temperature (less than 35.5°C* or feels cold) or • Movement only when stimulated or no movement even when stimulated.   POSSIBLE SERIOUS BACTERIAL INFECTION   Or   VERY SEVERE DISEASE  Give first dose of intramuscular Ampicillin and Gentamycin  Treat to prevent low blood sugar  Warm the young infant by skin-to-skin contact if temperature is less than 36.5°C (or feels cold to touch) while arranging referral  Advise mother how to keep the young infant warm on the way to the hospital  Refer URGENTLY to hospital   • Red umbilicus or draining pus or • Skin pustules   LOCAL BACTERIAL INFECTION  Give Cotrimoxazole or Amoxycillin for 5 days  Teach the mother to treat local infections at home  Advise mother when to return immediately  Follow-up in 2 days
  39. 39. Contd.. SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print) • Palms and/or soles yellow OR • Age < 24 hrs OR • Age 14 days or more     SEVERE JAUNDICE  Treat to prevent low blood sugar  Warm the young infant by skin-to-skin contact if temperature is less than 36.5°C (or feels cold to touch) while arranging referral  Advise mother how to keep the young infant warm on the way to the hospital  Refer URGENTLY to hospital • Only skin or eyes yellow   JAUNDICE  Advise mother to give home care for the young infant  Advise mother when to return immediately  Follow-up in 2 days
  40. 40. Diarrhea in Young infants • Relatively rare compared to the older child • Assessment, classification & management the same to the sick child except –The sign thirst not used in young infant –All Bloody and persistent diarrheas are referred to hospital for management
  41. 41. HIV Infection in Young InfantsHIV Infection in Young Infants Signs Classify Treatment • Positive PCR test in the young infant CONFIRMED HIV INFECTION • Give Cotrimoxazole Prophylaxis from 6 weeks of age • Refer for ARV • Assess feeding and counsel as necessary • Advise the mother on home care • Follow-up in 14 days • Mother HIV positive, OR • Child has positive HIV antibody test POSSIBLE HIV INFECTION (HIV EXPOSED) • Assess feeding and counsel as necessary • Give Cotrimoxazole Prophylaxis from 6 weeks of age • Confirm HIV status as soon as possible using PCR • Follow-up in 14 days • Negative HIV test in mother or child HIV INFECTION UNLIKELY • Treat, counsel and follow-up existing infections • Advise the mother about feeding and about her own health
  42. 42. Check for Feeding Problem or Low weight SIGN CLASSIFY AS TREATMENT If any of the following signs: • Not well positioned or • Not well attached to breast or • Not suckling effectively or • Less than 8 breastfeeds in 24 hours or • Switching the breast frequently or • Not increasing frequency of breastfeeding during illness or • Receives other foods or drinks or • The mother not breastfeeding at all or • Low weight for age or • Thrush (ulcers or white patches in mouth) FEEDING PROBLEM OR LOW WEIGHT  Advise the mother to breastfeed as often and for as long as the infant wants, day and night • If not well attached or not suckling effectively, teach correct positioning and attachment • If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding • Empty one breast completely before switching to the other • Increase frequency of feeding during and after illness  If receiving other foods or drinks, counsel mother about breastfeeding more, reducing other foods or drinks, and using a cup  If not breastfeeding at all: - Refer for breastfeeding counseling and possible relactation - Advise about correctly preparing breastmilk substitutes and using a cup  If thrush, teach the mother to treat thrush at home  Advise mother to give home care for the young infant  Follow-up any feeding problem or thrush in 2 days  Follow-up low weight for age in 14 days Not low weight for age and no other signs of inadequate feeding NO FEEDING PROBLEM  Advise mother to give home care for the young infant  Praise the mother for feeding the infant well
  43. 43. THANK YOU

×