Management of children under 5 years

1. Health Issues of Under-five
Children and IMNCI
Jyoti Sharma
MPH 2018
1

2. Overview
• Terminologies
• Global and national scenario of under five
children
• Causes of child mortality
• IMCI startegy
• CB-IMNCI
2

3. Terminologies
• Perinatal: 22nd weeks pregnancy to 7 days after birth
• Neonate: is a child after birth to 28 days of age.
• Early neonate: is a child after birth to 7 days of age.
• Late neonate: is a child after 7 days of birth and upto 28 days
of age.
• Infant: A child under the age of 1 year of age.
• Under-five children: A child from birth to 5 year of age.
3

4. Global Scenario
• Globally 2.6 million children died in the first month of life in 2016.
• There are approximately 7 000 newborn deaths every day, amounting
to 46% of all child deaths under the age of 5-years.
• Preterm birth, intrapartum-related complications (birth asphyxia or
lack of breathing at birth), and infections cause most neonatal deaths.
• From the end of the neonatal period and through the first 5 years of
life, the main causes of death are pneumonia, diarrhoea and malaria.
• Malnutrition is the underlying contributing factor, making children
more vulnerable to severe diseases.
4

5. Global Progress
• The global under-5 mortality rate has dropped by 56 per cent
from 93 deaths per 1000 live births in 1990 to 41 in 2016.
• The number of neonatal deaths declined from 5.1 million in
1990 to 2.6 million in 2016
• The neonatal mortality rate fell by 49 per cent from 37 (36, 38)
deaths per 1,000 live births in 1990 to 19 (18, 20) in 2016.
• Among all 195 countries analysed, 116 already met the SDG
target on under-five mortality and 27 countries are expected to
meet the target by 2030 if current trends continue, while 52
countries need to accelerate progress.
5

6. Child Health in Nepal
• The burden of child mortality is still high in Nepal. After much
prioritization and investment in child health programmes such
as nutrition, immunization, management of child hood
illnesses, and maternal and newborn survival programs,
still the progress we made is far from expectation.
• Biannual distributions of Vitamin A and Albendazole, Iodine
fortification of salt, Iron fortification in the wheat flour,
Routine immunization, mop up and supplementary
immunization activities and many other activities have helped
in achieving improved child health in Nepal.
•
6

7. Contd…
• Despite declining rates of undernourishment and child
mortality in recent years, malnutrition remains a serious issue
in Nepal.
• According to WFP, 41 percent of children younger than 5
years of age in Nepal are experiencing chronic malnutrition
and 11 percent suffer from acute malnutrition. Among
pregnant and lactating women, the prevalence of anemia was
approximately 46 percent and a staggering 74 percent among
children ages 12-17 months, according to the 2016 DHS.
7

8. Causes of child mortality, 2017
(WHO)
• The leading causes of death among children under five in 2017
were preterm birth complications, acute respiratory
infections, intrapartum-related complications, congenital
anomalies and diarrhea.
• Neonatal deaths accounted for 47% of under-five deaths in
2017.
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9. Leading causes of mortality of
under-five children in Nepal
9

10. 10

11. Some terminologies
• Neonatal mortality: the probability of dying within first
month of life.
• Post-neonatal mortality: the probability of dying after first
month of life up to one year of age.
[Infant mortality – neonatal mortality = post-neonatal mortality]
11

12. • Infant mortality: the probability of dying within first year
after birth.
• Child mortality: the probability of dying between exact ages
one and five years.
• Under-five mortality: the probability of dying up to the age
of five from the day of birth
12

13. • Under-five mortality rate is 33.7per 1,000 live births.
• Infant mortality rate (IMR), 28 deaths per 1,000 live births
• Neonatal mortality rate (NMR), 21 deaths per 1,000 live
births
• Under-five mortality rate (U5MR), 36 deaths per 1,000 live
births (male)
• Under-five mortality rate (U5MR), 31 deaths per 1,000 live
births (female)
13

14. Some of the development in Child health
policies, plans and programmes
Time Frame Activities
1959 Establishment of shree panch Indra Rajya Laxmi Devi prasuti Griha
(Maternity Hospital)
Family planning services by Family planning association of Nepal
1965 Family planning policy
FP/MCH project
First MCH clinic was established in 1965 under Bir Hospital Premises.
1968 Family planning and MCH project had 4 regional offices
1970 Kanti Hospital as children hospital
1977/78 Inception of EPI
1978 PHC Alma Ata
1990 Ratified the convention on the rights of the child 14

15. 1995 National Council for children
1998 Safe motherhood program
IMCI (Integrated management of childhood illnesses)
National Plan of Action on Nutrition
2004 National Nutrition policy and strategy, 2004
National neonatal health strategy 2004
2005 Infant and Young Child Feeding strategy
2006 National safe motherhood and newborn health long term plan (2006-2017)
2012 Multi-sector Nutrition Plan 2013-2017
2012 National Plan of Action for Children, Nepal 2004/05-2014/15
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16. Targets and indicators directly related to
Child health in Sustainable development goal
Targets and
Indicators
2017 2020 2022 2025 2030
Goal 2: Target 2.2 By 2030, end all forms of malnutrition, including achieving, by
2025, the internationally agreed targets on stunting and wasting in children under
5 years of age, and addressing the nutritional needs of adolescent girls, pregnant
and lactating women and older persons
2.2a Prevalence of
underweight
children <5 years
24.64 19.19 15.55 10.09 1
2.2b Prevalence of
stunted children
<5yrs
30.58 23.75 19.20 12.38 1
16

17. 2.2c Prevalence
of wasted
children <5 yrs
9.37 7.44 6.15 4.22 1
2.2d Proportion
of population
below minimum
level of dietary
energy
consumption
18.71 14.63 11.90 7.81 1
2.2e prevalence of
anaemia among
women of
reproductive age
31.47 24.44 19.75 12.72 1
17

18. 2.2f prevalence
of anaemia
among children
<5years of age
(%)
37.56 29.13 23.50 15.06 1
Goal 3: Target 3.2 By 2030, end preventable deaths of newborns and children under 5
years of age
3.2a Neonatal
mortality rate
(per 1000 LB)
17 14 11.3 8.5 1
3.2bUnder-five
mortality rate
(per 1000 LB)
28 23 18.4 13.8 1
18

19. IMCI
Strategy
• WHO--‐UNICEF Strategy: Launched in 1995
• OBJECTIVES
 To reduce significantly global mortality and morbidity
associated with the major causes of disease in children
 To Contribute to healthy growth and development of children
• Recommended for countries with U5MR >40
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20. • Integrated approach to promotion, prevention and
treatment:
 Management of sick child and focusing on the top killers.
 Address malnutrition: Assess nutritional status and anemia;
Counsel for breastfeeding and complementary feeding; Treat;
Refer for higher level care.
 Assess immunization and complete the schedule.
20

21. Introduction on (CB-IMNCI)
Program in Nepal
• Nepal has a long history of implementation of community
based maternal and child health programs.
• To improve the health status of under-five children,
Community Based Integrated Management of Childhood
Illness (CB-IMCI) program was introduced in 1997 and
initiated in Mahottari district as a pilot and nationwide scaling
up was completed in 2009.
• Fiscal year 2o66/67 (2009/2010) CB-IMCI covers all 75
districts.
21

22. • Likewise, Community Based-Newborn Care Program
(CBNCP) was designed (2008), piloting initiated (2009),
scaling up commenced (2011) and finally evaluation of 10
pilot districts was conducted in 2012.
• Based in part on the findings of CB-NCP assessment, CB-
IMCI and CB-NCP programs were integrated in October 14,
2014 and it was renamed as Community Based-Integrated
Management of Neonatal and Childhood Illness program (CB-
IMNCI).
22

23. • CB-IMNCI is comprised of both newborn and child survival
interventions. With regard to interventions targeted to newborn and
sick young infants CBIMNCI includes essential new born care,
counseling on breastfeeding and newborn complications (non
breathing babies at birth, neonatal sepsis, jaundice, hypothermia,
low birth weight and preterm births) as well as treatment of PSBI
at HP and PHCC.
• For children aged 2 to 59 months, it addresses major childhood killer
diseases such as pneumonia, diarrhea, malaria, and malnutrition.
23

24. • In CB-IMNCI, the primary role of FCHVs as health
promoters/educators and includes dispensing essential
commodities, for example, distribution of iron, zinc, ORS,
chlorhexidine etc.
• The role of health workers is to provide treatment services
especially on neonatal sickness and childhood illness.
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25. • As per WHO guideline, in CB-IMNCI program, amoxicillin is
the first line drug of choice for the treatment of neonatal sepsis
and pneumonia. Furthermore, CB-IMNCI program has
included various social and behavioral change community
level activities including demand generation activities for the
newborn and child health services, primarily undertaken by
FCHVs.
25

26. • Goal: Improve new born and child survival and healthy
growth and development.
• Targets of Nepal Health Sector Strategy (2015-2020)
 Reduction of Under-five mortality rate (per 1,000 live births)
to 28 by 2020
 Reduction of Neonatal mortality rate (per 1,000 live births) to
17.5 by 2020
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27. Objectives
1. To reduce neonatal morbidity and mortality by promoting
essential newborn care services.
2. To reduce neonatal morbidity and mortality by managing
major causes of illness
3. To reduce morbidity and mortality by managing major causes
of illness among under 5 years children
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28. Strategies
• Strengthen newborn and child health care services at different
levels
• Strengthen referral system for the management of sick
newborn and child
• Carry‐out context‐specific decentralized planning focusing on
underserved children (urban slums, marginalized,
disadvantaged groups and hard to reach areas).
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29. • Mobilize FCHVs of remote areas to prevent severity of
infection among newborn and treatment of pneumonia among
child
• Capacity building of HWs and FCHVs
• Improve quality of care at all levels.
• Ensure the year round availability of essential commodities,
equipment and supplies
29

30. • Improve collaboration with public and private sectors (state
and non‐ state) for standardized newborn and child health
services
• Carry out research/innovation to generate and use evidence for
informed programming
• Design and implement context specific demand generating
activities
• Strengthen home and community based practices and promote
community participation
30

31. • Benefits
Children can benefit from the diagnosis and treatment of
major childhood killer diseases (Pneumonia, Diarrhoea,
Malnutrition, Measles and Malaria).
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32. Key interventions include:
1. Newborn Specific Interventions
• Promotion of birth preparedness plan
• Promotion of essential newborn care practices and postnatal
care to mothers and newborns
• Identification and management of non breathing babies at birth
• Identification and management of preterm and low birth
weight babies
• Management of sepsis among young infants (0-59 days)
including diarrhea
32

33. 2. Child Specific Interventions
• Case management of children aged between 2‐59 months for 5
major childhood killer diseases (Pneumonia, Diarrhoea,
Malnutrition, Measles and Malaria)
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34. 3. Cross Cutting Interventions
• Behavior change communications for healthy pregnancy, safe
delivery and promote personal hygiene and sanitation
• Improved knowledge related to Immunization and Nutrition
and care of sick children
• Improved inter personal communication skills of HW sand
FCHVs
34

35. Service availability:
• The services are available at District Hospitals,
Primary Health Care Centres and Health Posts and up
to the community level.
35

36. • CB-IMNCI package was first introduced in Rasuwa, Nuwakot
and Nawalparasi districts in late 2014 with all trainings
delivered in a single phase (i.e. HF and community level
training done typically over a period of less than 6 months.
• In mid-2015, modality for introduction was revised and a
phase wise approach was adopted.
36

37. CB-IMNCI, was implemented in
three phases:
1. The first phase consists of situation analysis, district
planning, and trainings to selected health workers,
orientations (remaining HWs, Dhami/Jhankri, mothers group
etc.), community level trainings, onsite coaching and
implementation of SBCC activities.
2. The second phase consists of trainings of remaining health
workers, reviews, onsite coaching and monitoring,
3. The third phase consist of review of activities carried out in
the previous two phases.
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38. CB-IMNCI Program Monitoring
Key Indicators:
1. % of Institutional delivery
2. % of newborn who had applied Chlorhexidine gel
immediately after birth (within one hour)
3. % of infants (0-2 months) with PSBI receiving complete dose
of Injection Gentamicin
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39. 4. % of under 5 children with pneumonia treated with antibiotics
5. % of under 5 children with diarrhoea treated with ORS and
Zinc
6. Stock out of the 5 key CB-IMNCI commodities at health
facility (ORS, zinc, gentamicin, amoxicillin/ cotrim, CHX).
All program monitoring indicators except number six are
related to HMIS.
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40. Vision 90 by 20
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41. Major activities carried out under the IMNCI
programme in FY 2073/74 were as follows:
• Development and certification of Mid-western Regional
Hospital as an IMNCI Clinical Training Site as Nepal’s first
IMNCI Clinical Training Site
• Expansion of IMNCI Training Site at Pokhara (Pokhara
Academy of Health Science) and Dang (Rapti Sub-regional
Hospital): On-going
• Development of National Medical Standard for Care of
Newborns and Children has been started: On-going
41

42. Contd…
• Development a pool of IMNCI trainers for CB-IMNCI and
Comprehensive Newborn Scale up of Navi care Program in
public as well as private sector
• Development of FB-IMNCI (Facility- based IMNCI)
package: On-going
• Implementation of Remote Area Guideline for CB-IMNCI
program (on-going)
42

43. Contd…
• Procurement of commodities and equipment related to IMNCI
• Establishment/Strengthening of SNCU (Sick newborn Care
Unit)
• Printing of CB-IMNCI, Comprehensive New born Care (Level
II) Training Materials (Guidelines, Handbook, Chart, Flex,
etc.)
• Training of Trainers (TOT) for CBIMNCI and Comprehensive
Newborn Care Training (Level II)
43

44. Contd…
• Implementation of free sick newborn care program through
five hospitals (Kanti Children
• Hospital, Koshi Zonal Hospital, Western Regional Hospital,
Lumbini Zonal Hospital and Seti Zonal Hospital)
• Initiation of Perinatal Quality Improvement Initiative in 12
hospitals
44

45. CB-IMNCI programme monitoring indicators
by province (FY 2073/74)
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46. IMCI Strategy: Addresses major causes of
mortalityand morbidityin under‐five children
46
Young infant: Upto 2 months
• Sepsis and serious disease
• Local infections
• Diarrhoea
• Feeding problem
• Immunization
• Additions: Jaundice
Child: 2 Months up to 5 years
• Severe illness
• Pneumonia
• Diarrhoea
• Measles, Malaria
• Middle ear infection
• Anemia and undernutrition
• Additions: Dengue, Asthma,
Pharyngitis, UTI, HIV
Prevention:
• Nutrition: Breastfeeding, complementary feeding
• Immunization
• WASH advise
• Seeking treatment and Referral

47. 47

48. 48

49. Assess, classify and treat the sick young
infant age less than 2 months
49

50. Contd…
50

51. 51

52. 52

53. Feeding problem
53

54. Assess, classify and treat Sick child
age 2 months to 5yrs
54
Signs Classify As Treatment

55. Diarrhoea
55

56. contd…
56

57. 57

58. Mastoiditis
58

59. 59

60. 60

61. Malnutrition
61

62. Anemia
62

63. 63

64. 64

65. 65

66. 66

67. Classification of cases as per CB-IMNCI
protocol by province (FY 2073/74)
67

68. Feeding recommendations during
sickness and health
68

69. 69

70. 70

71. 71

72. 72

73. References
• https://www.who.int/countries/npl/en/
• http://www.searo.who.int/nepal/mediacentre/concept_not
e_tor_on_cbimnci_assessment.pdf
• https://data.unicef.org/country/npl/
• Annual report 2073/74
• http://www.health.gov.bt/wp-
content/uploads/ftps/imnci/IMNCI%20for%20RIHS/IMNC
I%20Students%20Handbook.pdf
73