INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS(IMNCI)

1. INTEGRATED
MANAGEMENT OF
NEONATAL AND
CHILDHOOD ILLNESS
(IMNCI)

2. Introduction
 Over the last 3 decades
– Annual no. of deaths among children <5
yrs has decreased almost a third
– But not been evenly distributed
worldwide
– In India IMR 60/1000 and Under 5
mortality 95/1000 live births per year.
Neonatal mortality contributes to 64% of
infant deaths mostly occurring during first
week of life

4. Important MCH indicators –
Current Status vs. Goals
Current X 5th year
plan
2010
IMR 60 (SRS
2000)
45 < 30
NMR 26 (SRS
2000)
26 < 20
MMR 407
(NFHS I)
200 < 100

5. An integrated approach was needed
to manage sick children to achieve
better outcomes.
Child health programmes needed to
move beyond tackling single diseases
in order to address the overall health
& well being of the child
During mid 1990s, WHO & UNICEF
developed a strategy – IMCI.

6. IMCI
Curative care
Also
– Nutrition
– Immunization
– Disease prevention
– Health promotion

7. Limitations of IMCI
 Though it is an accepted standard for
managing & improving child health, it did
not include care for the infant in 1st week of
life
 A continuum of care thro pregnancy,
delivery and into childhood is crucial for
both neonatal and maternal health and
survival.
 Yet there was a major gap in the
continuum
Only collaborative action could integrate
newborn health into the continuum of care.

8. IMCI has been expanded in
India to include all neonates
and renamed as IMNCI
Govt of India has made newborn health a
priority in the nation’s next five year plan
Govt is working with WHO and UNICEF to
adapt IMCI guidelines to include newborn
care, creating new guidelines called
IMNCI

9. IMNCI
 Interventions to prevent & manage 5 major
childhood illnesses- ARI, Diarrhea,
Measles, Malaria and Malnutrition
 Focuses on preventive, promotive and
curative aspects
 Evidence based syndromic approach to
determine
– Health problem(s)
– Severity of the condition
– Actions that can be taken

10. Target age group < 5 yrs - that bears the
highest burden of deaths & common
childhood diseases

11. GOALS
 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

12. ESSENTIAL COMPONENTS
 Improve health and nutrition workers’ case
management skills
 Improve health systems
 Improve family and community health care
practices
First 2 are facility based and the third is
community based IMNCI
In addition, promotes
 adjustment of interventions to the capacity
of the health system
 active involvement of family members & the
community in health care process

13. 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

14. 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.

15. Colour coded case
management strategy
 PINK CLASSIFICATION: Child needs
inpatient care
 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

16. What does IMNCI not provide at all or
fully
 Antenatal care
 Skilled birth attendance
 Improved health system
management

17. Outpatient Management of Young Infants
up to 2 months of age
Assessment
Classification
(rather than a diagnosis)
Management

18. Possible Serious Bacterial infection
 Convulsions
 Fast breathing (≥ 60/mt)
 Severe chest indrawing
 Nasal flaring
 Grunting
 Bulging fontanelle
 ≥ 10 skin pustules or a big boil
 Temp ≥ 37.5* C or ≤ 35.5*C
 Lethargy or unconsciousness
 Less than normal movement

19. Local bacterial Infection
Umbilicus red or draining pus
Pus draining from ear
< 10 skin pustules

20. Severe Jaundice
Yellow palms and soles
< 24 hrs of age
≥ 14 days of life
Jaundice
Palms and soles not yellow
Age 1-13 days
Low body temperature
Temp between 35.5* - 36.4* C

21. Diarrhea
Stools have changed from usual
pattern & are many and watery
Categories
– Acute watery diarrhea
– Dysentery
– Persistent diarrhea
Assessment
– Signs of dehydration
– Duration
– Blood in stools

22. Severe dehydration
– Lethargy / unconsciousness
– Sunken eyes
– Skin pinch goes back very slowly
Some dehydration
– Restless, irritable
– Sunken eyes
– Skin pinch goes back slowly
No dehydration
– No enough signs to classify

23. Feeding problems and Malnutrition
– Is there feeding difficulty
– Breast fed how many times
– Any other feed / drinks & what
Assess Breast Feeding
– Good signs of attachment
– Effective suckling
– Oral cavity examination

24. Determine Weight for Age
– Calculate age in weeks
– Weigh that day
– Use Wt for Age chart
Very low Wt for Age
Low Wt for Age
Not low Wt for Age

26.  Serious bacterial infection / severe
malnutrition
– Not able to feed
– No attachment at all
– Not sucking at all
– Very low Wt for age
 Feeding problem / low Wt
– not well attached to breast
– Not sucking well
– < 8 breast feeds / day
– Receiving other feeds
– Low Wt for Age
 No feeding problem
– Not low Wt for Age
– No other signs of inadequate feeding

27. Immunization Status
Schedule
 Birth – BCG, OPV 0
 6 weeks – DPT1, OPV1, Hep B 1*
No OPV who is more than 14 days old, if
missed at birth

28. TREATMENT
Referral to hospital
– as soon as assessment is complete
– Necessary pre-referral treatment given
– Referral note
Treatment in outpatient clinic
– Local bacterial infection- oral antibiotics
– Some dehydration – Plan B
– Feeding problem / Low Wt – advice
– Umbilicus infection – 0.5% GV
– Oral Thrush – 0.25% GV

29. Pre-medications – severe category

30. Medications – outpatient category

31. Good position of breast feeding
Method of expressing breast milk
and feeding with spoon
Tackling breast and nipple
problems
Advise when to return
– Immediately
– 2 days
– 14 days
– Next well-child visit
Counsel the mother about her own
health

35. For the Sick Young Infants up to 2 months of age

37. Outpatient management of Sick child from
2 months to 5 years of age
Assessment
– History taking & communication with care
taker
– Checking for general danger signs
– Checking main symptoms
– Checking malnutrition
– Check for anemia
– Assess feeding
– Check immunization status
– Assess other problems

38. General Danger Signs
Convulsions
Unconsciousness / lethargy
Unable to drink / breast feed
Vomits everything
If one or more is present – Seriously ill
Then quickly assess for most
important causes of serious illness
and death

39. Main Symptoms
Cough / difficult breathing
– Resp rate: 2m to 12 m – ≥50/m; 12m to
5 yrs – ≥40/mt.
– Lower chest indrawing
– Stridor
Diarrhea
Fever
Ear problems

40. Pneumonia
 Severe pneumonia / very severe disease
– Any danger sign
– Chest indrawing
– Stridor in a calm child
 Pneumonia
– Fast breathing
 No pneumonia: cough/cold
– No signs of pneumonia / very severe disease

42. Diarrhea
3 or more loose / watery stools in a 24
hr period
Common between 6 m to 2 yrs
Potentially lethal
– Acute watery diarrhea (incl. Cholera)
– Dysentery
– Persistent diarrhea
Assess
– Dehydration
– Duration
– Blood in stools

43. Severe dehydration: 2 of the following
– Lethargy / unconsciousness
– Sunken eyes
– Not able to drink/drink poorly
– Skin pinch goes back very slowly
Some dehydration
– Restless / irritable
– Sunken eyes
– Drinks eagerly, thirsty
– Skin pinch goes back slowly
No dehydration
– No enough signs to classify

45. Fever
Body temp >37.5*C axillary (38*C
rectal)
In absence of thermometer: feel hot
Assess
– Risk of Malaria
– Duration of fever
– Bulging fontanelle
– Stiff neck
– Runny nose – common cold
– Measles: Rash

46.  Very severe febrile disease
– Any danger sign
– Stiff neck
– Bulging fontanelle
 Malaria
– Fever (by history/touch/thermometer)
– No runny nose
– No other causes of fever
 Fever malaria unlikely
– Runny nose present
– Measles present
– Other causes of fever present

47. Measles
Severe complicated
– Any danger sign
– Clouding of cornea
– Deep / extensive mouth ulcers
With eye or mouth complications
– Pus draining from eye
– Mouth ulcers
Measles
– Measles now or within the last 3 months

48. Ear Problems
Mastoiditis
– Tender swelling behind ear
Acute ear infection
– Pus is seen draining from the ear and
discharge for <14 days
– Ear pain
Chronic ear infection
– Pus is seen draining from the ear &
discharge for ≥14 days
No ear infection
– No ear pain / ear discharge

49. Malnutrition
 Reasons for assessment
– To identify children with severe malnutrition who
are at risk of mortality & need urgent referral
– To identify children with sub-optimal growth
resulting from ongoing deficits in diet + recurrent
infections
 Clinically
– Visible severe wasting: shoulder, arms,buttock
and legs - MARASMUS
– Edema of both feet - KWASHIORKAR
– Weight for Age: Standard WHO growth chart
• <-2SD low Wt for Age
• <-3SD very low Wt for Age

50. Severe malnutrition
– Visible severe wasting
– Edema of both feet
Very low Wt for Age
– Very low Wt for Age
Not Very low Wt for Age
– Not very low Wt for Age & no signs of
severe malnutrition

52. Anemia
Common cause – malnutrition
Clinically – palmar pallor
Severe anemia
– Severe palmar pallor
Anemia
– Some pallor
No anemia
– No pallor

54. Feeding
 All children <2 yrs even if they have normal
Z score, & all children classified as anemia
or very low Wt for Age need to be
assessed for feeding
– Breast feeding frequency & night feeds
– Types of complimentary feeds & frequency
– Feeding pattern due to current illness
 Identify feeding problems
– Difficulty in breast feeding
– Use of feeding bottle
– Lack of active feeding
– Not feeding well during illness

55. Immunization, Vit A & folic acid
supplementation Status
 Illness is not a contraindication to immunize
 A vaccine’s ability to protect is not
diminished in sick children
 Only 4 common situations are
contraindications for vaccination
– Child whom is being referred urgently to the
hospital
– Live vaccines to immunodeficient children
– DPT2/DPT3 to a child who has had convulsions
/ shock in last 3 days
– DPT to a child with recurrent convulsions

56. Treatment
Referral to hospital
– As soon as assessment is complete
– Pre – referral treatment
Treatment in out patient clinics

57. Pre – referral treatment

60. Treatment as OP basis

66. Counselling mother / Care taker
To continue feed / increase fluids
Teach how to give oral drugs
Counsel to solve feeding problems
Advise when to return
– Immediately
– 2 days
– 5 days
– 14 days
– 30 days
– Next well child visit
Follow up care

67. For the Sick Child from 2 months to 5 years of
age

69. Principles of Management of Sick
children in a Small Hospital
 First step – TRIAGE
– Those with emergency signs
– Those with priority signs
– Non – urgent cases
 Lab investigations
– Hb / PCV
– Smear for Malarial parasite
– Microscopy CSF/Urine
– Blood grouping and cross matching
– S.bilirubin (for young infants)
– CXR & stool microscopy (not essentially)

70.  Detailed information of management of
children in First – Referral Hospital are in
manual “MANAGEMENT OF CHILD WITH
A SERIOUS INFECTION OR SEVERE
MALNUTRITION: GUIDELINES FOR
CARE AT THE FIRST REFERRAL LEVEL
IN DEVELOPING COUNTRIES”
 Key aspects in monitoring child’s progress
– Devising a monitoring plan
– Using a standard chart to record essential
information
– Bringing these problems to the notice of senior
staff

71. STUDENTS HANDBOOK FOR
IMNCI - 2003
4 CHAPTERS
– Integrated management of neonatal and
childhood illness
– Outpatient management of young infants
age up to 2 months
– Outpatient management of children age 2
months up to 5 years
– Principles of management of sick
children in a small hospital