Integrated management of neonatal child illness ,a national health program for 6th mbbs as well as for long case in the field

1. Dr. E Srikaanth Reddy
•Associate Professor in Community Medicine
•Ex-National Medical Consultant in N.T.EP,
World Health Organization , INDIA, posted at
Odisha 2019-2020

2. Integration tackles the need for complementarily
of different independent services and
administrative structures to achieve the common
goals in a better way.
It has different meanings at different levels:
 at the patient level – case management.
 at the point of delivery – multiple interventions
are provided through one delivery channel. E.g.,
providing vit-A through vaccination programme.
 At the system level – bringing together
management of different sub-programes and
ensuring complementarily between different
levels of care.
 IMCI is the only child health strategy that aims
for improved integration at these three levels
simultaneously.

3.  Most of the children of low and middle income
countries die before they reach their 5th
birthday.
 Most sick children present with signs and
symptoms related to more than one condition.
 This overlap leads to inappropriate diagnosis
and the treatment may be complicated by the
need to combine therapy for several
conditions.
 To provide quality care to the children WHO
and UNICEF developed a strategy known as
IMCI.
 This combines the improved management of
childhood illness with aspects of nutrition,
immunization and other health promotion
elements.

4.  To reduce mortality and frequency of illness
and disability.
 To contribute to improve growth and
development.
 To reduce wastage of resources in cost
effective manner.
 To avoid duplications of effort.

5. The strategy has three main components:
 Improvements in the case-management
skills of health workers through provision
of locally adapted IMCI guidelines.
 Improvements in health system –
 District planning and management
 Availability of IMCI drugs
 Quality improvement supervision at health
facilities
 Health information systems
 Referral pathways and services
 Improvements in family and community
practices.

6.  The clinical guidelines, which are based on
expert clinical opinion and research results,
are designed for the management of sick
children aged 1 week up to 5years .
 They promote evidence based assessment
and management , using a syndromic
approach that supports the rational,
effective and affordable use of drugs.
 The case management process is presented
on two different sets of charts- one for
children age 2months up to 5 years.
- one for children age 1 week up to 2
months.

7. The guidelines include –
 Methods for assessing the signs that indicate
severe disease.
 Assessing child’s nutrition, immunization,
feeding
 Teaching parents how to care for a child at
home
 Counseling parents to solve feeding problems
 Advising parents about follow up
 Recommendations for checking parents
understanding of the advice
 For showing them how to administer the first
dose of treatment

8.  The guidelines do not describe the
management of trauma or other acute
emergencies due to accidents or injuries
 A child with chronic problems and less
common illness may need special care
 AIDS is not addressed specifically

9.  IMNCI is Indian adaptation of WHO-UNICEF
generic IMCI .
 It includes the management of children
aged 0-6 days (early neonates) apart from
1week to 5years age that included in IMCI.
 It focuses on home based care by providers
like ANMs and AWWs.

10. Acute Respiratory
Infections*
19%
Diarrhoea*
19%
Measles*
Malaria*
5%
Other
32%
Perinatal
18%
Malnutrition*
54%
•Based on data taken from The Global Burden of Disease 2022, edited by Murray CJL and
Lopez AD, and Epidemiologic evidence for a potentiating effect of malnutrition on child
mortality, Pelletier DL, Frongillo EA and Habicht JP, AMJ Public Health 1993;83:1130-1133
7%

11.  The IMNCI package has been developed by experts
including the child health researchers academicians
the Indian academy of pediatrics (IAP) and the
national neonatology forum (NNF) to adapt it for
specific requirements in India.
 Newborn care is an important issue for bringing
down infant mortality rate in India.
 This package includes :
Care of newborns and young infants (infants
under 2 months)
Care of infants (2 months to 5 years)

12.  All sick young infants aged up to 2 months must
be examined for-
possible serious bacterial infection / jaundice.
 All children 2months to 5years for- general danger
signs which indicate the need for immediate
referral or admission to a hospital.
 All sick children must be routinely assessed for
major symptoms and for nutritional and
immunization status, feeding problems, and other
potential problems.
 Only a limited number of carefully selected clinical
signs are used to detect disease.
 A combination of signs leads to a child’s
classification rather than a diagnosis which indicate
the severity.
 This is a color coded classification.

13. 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 NAMP
• Home-based care of young infants by health
workers added

14. Check for danger signs
Assess main symptoms
Assess nutrition and immunization status
and feeding problems
Check for other problems
Classify conditions

15.  The classifications are color coded.
 They call for specific actions based on whether the young infant
or the child should be urgently referred to another level of care,
or requires specific treatments or may be safely managed at
home.
pink
Urgent referral
•Pre-referral treatments
•Advise parents
•Refer child
•Referral facility
ETAT
Diagnosis treatment
Monitoring and follow-up
yellow
Treatment at out
patient health
facility
•Treat local infection
•Give oral drugs
•Advise care taker
•Follow-up
Green
Home management
care taker is counseled on
how to:
•Give oral drugs
•Treat local infection at home
•Continue feeding
•When to return immediately
•Follow-up

16.  Assess possible bacterial infection / jaundice
 Ask the infant has diarrhea
 Check for feeding problems and malnutrition
 Check for immunization status and other
problems

18.  Ask: has the infant had convulsions?
 Look , listen and feel for:
 Count the breaths in one minute. Repeat the count if high.
 Look for chest indrawing and nasal flaring
 Look and listen for grunting
 They are significant only when the infant is calm during
observation as they can be present when the infant is crying.
• Look and feel for bulging fontanelle
• Look for pus draining from ear
• Look at the umbilicus
• Look for skin pustules
• See if the young infant is lethargic or unconscious

19. Signs Classify as Identify treatment
•Convulsions or fast breathing
(60/min or more)
•Severe chest in drawing
•Nasal flaring or grunting
•Bulging fontanelle , 10 or more skin
pustules or a big boil
•Temperature > or < 37.5ºc
•Lethargic or unconscious
•Less than normal movements
Possible serious
bacterial infection
Give 1st dose of i.m.
ampicillin and gentamicin
Treat to prevent low blood
sugar
Warm the infant by skin to
skin contact
Advise mother how to keep
young infant warm on the way
to the hospital
Refer urgently to hospital
•Umbilicus red/ draining pus
•Pus discharge from ear
•< 10 skin pustules
Local bacterial
infection
Give oral drugs for 5 days
Teach mother to treat local
infections at home
Follow up in 2 days

20. Signs Classify as Identify treatment
•Palms and soles yellow
•Age <24 hours
•Age 14 days or more
severe jaundice Treat to prevent low blood
sugar
Warm the young infant
Advise mother to keep the
young infant warm
Refer urgently to hospital
Palms and soles not yellow jaundice Advise mother to give home
care for the young infant
Advise her when to return
immediately
Follow up in 2 days
Temperature between 35.5-36.4ºc low body
temperature
Warm the young infant
Reassess after one hour
Treat to prevent low blood
sugar

21.  If the young infant has diarrhea
Ask : for how long? Is there blood in the stool?
Look and feel for:
 Look for general condition: lethargic or unconscious,
restless or irritable
 Look for sunken eyes
 Pinch the skin of the abdomen: does it go back very
slowly (>2 sec) or slowly.
 Classify for dehydration , acute or persistent diarrhea or
dysentery.
 Diarrhea for > or = 14 days in infants upto 2 months of
age is classified as severe persistent diarrhea and blood
in stool as severe dysentery.

22. Signs Classify as Identify treatment
2 of the following signs:
•Lethargic or unconscious
•Sunken eyes
•Skin pinch goes back very
slowly
severe
dehydration
If the infant has low birth weight or another
severe classification :
Give 1st dose of i.m amp and gen
Refer URGENTLY to hospital with mother
giving sips of ORS
Advise mother
If the infant does not have low birth weight –
give fluid for severe dehydration and refer to
hospital
2 of the following signs:
Restless irritable
Sunken eyes
Skin pinch goes back slowly
some
dehydration
If the infant has low birth weight:
Urgent pre referral treatment
If the infant does not low birth weight:
Give fluids for some dehydration
Follow up in 2 days
Not enough signs to classify as
severe or some dehydration
no
dehydration
Give fluids to treat diarrhea at home
Advise mother when to return immediately
Follow up in 5 days

25. Signs Classify as Identify treatment
Diarrhea lasting for 14 days
or more
severe persistent
diarrhea
If the infant has low birth weight or
another severe classification :
Give 1st dose of i.m amp and gen
Refer URGENTLY to hospital
Advise mother to keep the infant
warm
Blood in stool severe dysentery If the infant has low birth weight or
another severe classification :
Give 1st dose of i.m amp and gen
Refer URGENTLY to hospital
Advise mother to keep the infant
warm

26.  Ask :
 For any difficulty in feeding
 Is the infant breastfed? If yes, how many times in
24 hrs ?
 Does the infant receive any other foods or drinks
Determine weight for age
If the breast feeding is less < 8times in 24 hrs
Low weight for age
Any difficulty in feeding-
then look for ulcers or white patches
in the mouth
if there is a blocked nose

27.  Check for danger signs
 Assessment of main symptoms
 Assess nutrition and immunization status and
feeding problems
 Check for any other problems

28.  Has the child had convulsions
 Lethargy or unconsciousness
 Inability to drink or breastfeed
 Vomiting
 If the child has one or more of these signs , child is
considered to be seriously ill.
 Assess the child quickly for most important causes of
illness and death- ARI , Diarrhea, fever (associated with
malaria and measles).
 A rapid assessment of nutritional status is essential as
malnutrition is another main cause of death.
 Give pre-referral treatment and refer to a hospital.

29.  Cough or difficult breathing
Ask :for how long the child has
cough
Look and listen:
count the breaths in one
minute
look for chest indrawing
look and listen for stridor
Child must be calm while observing

30. Signs Classify as Identify treatment
•Any general danger sign or
•Chest indrawing or
•Stridor in calm child
Severe pneumonia
or very severe
disease
Give 1st dose of injectable
chloramphenicol or oral amoxicillin .
Refer urgently to hospital
Fast breathing :
2 months-12 months: R.R >50
per minute
12 months to 5 years: R.R >40
per minute
Pneumonia
Give cotrimoxazole for 5 days.
Soothe the throat and relieve the
cough with a safe remedy if child is 6
months or older.
Advise mother when to return
immediately.
Follow-up in 2 days.
No signs of pneumonia or
very severe disease. No pneumonia
If cough >30 days , refer for
assessment.
Soothe the throat and relieve the
cough with a safe remedy if child is 6
months or older.
Advise mother when to return
immediately.
Follow up in 5 days if not improving

31.  Ear pain , discharge from ear and
duration
 Look for pus draining from the ear
 Feel for tender swelling behind the ear
Signs Classify as Identify treatment
Tender swelling behind the ear. Mastoiditis Give 1st dose of injectable
chloramphenicol or oral amoxicillin .
give 1st dose of paracetamol for
pain.
Refer to hospital
Pus draining from the ear and
discharge is reported for <14 days
Ear pain
Acute ear infection Dry the ear by wicking
Follow-up in 5 days
Pus is seen draining from the ear and
discharge is reported for 14 days or
more.
Chronic ear infection Dry the ear by wicking
Follow-up in 5 days

32.  Look for palmar pallor and classify anemia as :
Signs Classify as Identify treatment
Severe palmar pallor Severe anemia Refer urgently to hospital
Some palmar pallor Anemia Give iron folic acid therapy for 14
days
Assess child’s feeding and follow up
in 5 days if any problem
Advise mother when to return
immediately
Follow-up in 14 days
No palmar pallor No anemia Give prophylactic iron folic acid if
child 6 months or older

33.  Improve health and nutrition workers’
skills
 Improve health systems
 Improve family and community
practices
Essential components of IMNCI

34.  Guidelines for management of sick newborns and
children with serious disease in first referral facilities
 Training course for doctors for outpatient management
of sick young infants and children
 Training course for health and nutrition workers for:
 Management of sick young infants and children
 Home visits for young infants
Improving health & nutrition worker skills

35.  Ensuring availability of the essential drugs with the workers and at facilities covered
under IMNCI.
 Improve referral to identified referral facility.
 Every health worker must be aware of where to refer the sick child and the staff at
the health facilities must be in a position to give priority care to the sick children.
 Ensuring availability of health workers / providers at all levels.
 Ensuring supervision and monitoring through follow up visits by trained
supervisors.

36. Counseling of families
Creating awareness among communities on
their role in improving the child health.
 promoting healthy behaviors such as
breastfeeding , illness recognition , early case
seeking.
 campaigns for awareness generation.
 counseling of care takers and families as a part
of management of sick child when they are
brought to the health worker or health facility.
 home visits- provide an opportunity for
identification of sickness

37. Home visits for young infants:
Objectives
• Promote & support exclusive breastfeeding
• Teach the mother how to keep the young infant
warm
• Teach the mother to recognize signs of illness for
which to seek care
• Identify illness at visit and facilitate referral
• Give advise on cord care and hand washing

39. 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.
Home visits for young infants:
Schedule

40.  IMNCI is a child intervention to be implemented
as apart of RCH phase-2 . Training for IMNCI
will therefore be a part of overall training plan
under RCH phase-2.
 Physician
◦ 3 batches of TOT conducted in KSCH Delhi
◦ 2 batches in Vellore district
 Workers
◦ TOT conducted in Jhalawar, Valsad & Vellore
districts
◦ H&N workers of 1 PHC of Osmanabad & 2 SCs
of Shivpuri

41.  Separate training material (training module, chart
booklet, photo booklet and video) developed for
◦ Physician
◦ Health and nutrition workers
 Workers training material translated in Hindi,
Marathi, Gujarati and Tamil.

42.  Evidence based decision making tree
 Feasible to incorporate into both pre-service
education & in-service training
 Hands-on clinical practice for 50% of training
time
 Focus on communication & counselling skills
 Locally adapted recommendations for infant
and young child feeding

43. Strengthening
Health Facility
Improvement in
HW Skills
Clinical
Management
Skills
Counseling
Skills
Facility
Support
Case
Management
Record
Forms
Caretaker
Interviews
Checklist
for
Facility Support
Tools

44. What does IMNCI not provide at all or
fully
• Antenatal care
• Skilled birth attendance
• Improved health system management
What can be rapidly added to IMNCI
• Inpatient care modules for first level referral hospitals

45. Challenges
• Feasibility of the proposed hands-on clinical
practice in management of young infants at
district level
• Feasibility of provision of health care at sub-
centre and village level by ANMs and Anganwadi
Workers
• Making the home-based care of young infants by
ANMs and anganwadi workers operational
• Improving logistics and supplies
• Sustaining what is initiated through indicator
based monitoring