imnci helps the health care workers to care for children below five years in the hospital, and home

1. Integrated Management of
Neonatal and Childhood Illness
B.SUDHA
PROFESSOR
VMCON

2. Introduction
• Every year more than 10 million children die in
developing
countries before they reach their fifth birthday.
• 7 in 10 of these deaths are due to five preventable and
treatable conditions.
• Pneumonia, diarrhea, malaria, measles and
malnutrition – and often to a combination of these
conditions.
• 3 out of 4 of these children suffer from one of these five
conditions.
2

3. 3

4. 4

5. • Projections based on the 1996 analysis indicate that common
childhood illnesses will continue to be major contributors to child
deaths through the year 2020 unless greater efforts are made to
control them.
• This assumption makes a strong case for introducing new strategies
to significantly reduce child mortality and improve child health and
development.
• WHO and UNICEF recognized the need to strengthen child-health
activities in the country and decided to launch IMCI.
• The generic IMCI guidelines were adapted and the Indian version
was named Integrated Management of Neonatal and Childhood
Illness (IMNCI)-main intervention under RCH-II/NRHM ,that
focuses on preventive, promotive and curative aspects of program.
5

6. • Why Newborn in India
• 1st Hour 1st Day 1stWeek 1st Month- death rate is
more
• Reasons for the delay in assessment and accessibility
of new born to reach healthcare setting:
1.Starting of a problem
2. Delay in recognizing problem
3.Home based treatment
4.Delay in selecting health facility
5.Treatment from traditional advisors and village doctors
6.Delay in selecting formal health facility causing delay in
treatment and increased cost
7.Increased chances of death of new born.
6

7. What is IMNCI ?
• IMNCI is an integrated approach to child health that focuses on the
well-being of the whole child. IMNCI aims to reduce death, illness
and disability, and to promote improved growth and development
among children under five years of age.
• IMNCI includes both preventive and curative elements that are
implemented by families and communities as well as by health
facilities.
•The strategy includes three main components:
Improving case management skills of health-care staff
Improving overall health systems
Improving family and community health practices
7

8. Guidelines for IMNCI
• Evidence-based, syndromic approach to case management
includes rational, effective and affordable use of drugs and
diagnostic tools.
• An evidence-based syndromic approach can be used to determine
the:
• Health problem(s) the child may have.
• Severity of the child’s condition, and
• Actions that can be taken to care for the child (e.g. refer the child
immediately, manage with available resources, or manage at home).
• In addition, IMNCI promotes:
• Adjustment of interventions to the capacity of the health system,
and
• Active involvement of family members and the community in the
health care process.
8

9. IMNCI Process
9

10. Principles of integrated care
• All sick young infants up to 2 months of age must be assessed for
“possible bacterial infection / jaundice”. Then they must be
routinely assessed for the major symptom “diarrhoea”.
• All sick children age 2 months up to 5 years must be examined for
“general danger signs” which indicate the need for immediate
referral or admission to a hospital. They must then be routinely
assessed for major symptoms: cough or difficult breathing,
diarrhoea, fever and ear problems.
• All sick young infants and children 2 months up to 5 years must
also be routinely assessed for nutritional and immunization status,
feeding problems, and other potential problems.
10

11. Principles of integrated care
(Contd. .)
• A combination of individual signs leads to a
child's classification(s) rather than diagnosis.
• - needs urgent hospital referral or admission
( classified as and colour coded pink)
• - needs specific medical Rx or advice
(classified as and colour coded yellow)
• - can be managed at home
(classified as and colour coded green)
11

12. Principles of integrated care
(Contd. .)
• IMNCI use a limited number of essential drugs
and encourage active participation of caretakers
in the treatment.
• IMNCI address most, but not all, of the major
reasons a sick child is brought to a clinic.
• One of essential component of IMNCI is the
counselling of caretakers about home care,
feeding, fluids and when to return to health
facility.
12

13. Goals of IMNCI
• 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
13

14. Elements of case management
process
• Assess - Child by checking for danger signs by history
and examination.
• Classify - Child's illness by color coded triage system.
• Identify - Specific treatments.
• Treatments- Instructions of oral drugs, feeding & fluids.
• Counsel - Mother about breast feeding & about her
own health as well as to follow further instructions on
further child care.
• Follow up care - Reassess the child for new problems
14

15. The CASE MANAGEMENT PROCESS
• Is Used To Assess And Classify Two Age
Groups
• Management Of The Young Infant Age Up To
2Months Is Presented On Two Charts
Assess and classify the sick young infant age
up to 2 months.
Treat the young infant and counsel the
mother.
15

16. Assess and classify the sick young
infant up to 2 months
19ASK:-
•Has the infant had convulsions ?
LOOK ,LISTEN ,FEEL:-
•Count the breaths in one minute .repeat the count
•Look for severe chest indrawing
•Look for nasal flaring
•Look and listen for grunting
•Look and feel bulging fontanelle
•Look for pus draining from the ear
•Look at the umbilicus-is it red or draining pus ?
•Look for skin pustules. Are there 10 or more skin pustules or a big boil
•Measure axillary temp.
•See if the young infant is lethargic or unconscious
•Look at the young infant’s movements. Are they less than normal?
•Look for jaundice. Are the palms and soles yellow?
16

17. SIGNS
•Convulsions or
•Fast breathing(60 breaths
per minute or more)
•Severe chest in drawing
•Nasal flaring
•Grunting
•Bulging fontanelle
•10 or more skin pustules or
a big boil If axillary temp>=
37.5 or temp<=35.5 degree
celsius
•Lethargic or unconscious
•Less than normal
movements
CLASSIFY
AS
POSSIBLE
SERIOUS
BACTERIAL
INFECTION
IDENTIFY TREATMENT
Give first dose of
intramuscular ampicillin and
Gentamicin
Treat to prevent low blood
Sugar
Warm the young infant by
skin to skin contact if
temperature 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
17

18. Umbilicus red or
draining pus
•Pus discharge from ear
Or
•< 10 skin pustules
LOCAL
BACTERIAL
INFECTION
Give oral cotrimoxazole
Or amoxycillin for 5
Days
Teach mother to treat
local infections at
Home
Follow up in two
days
18

19. SIGNS
•Palms &soles yellow
•Age <24hrs or
•Age >=14 days
CLASSIFY AS
SEVERE JAUNDICE
IDENTIFY TREATMENT
Treat to prevent low blood
sugar
Warm the young infant by
skin to
skin contact if temperature
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
•Palms& soles not
yellow
JAUNDICE Advise mother to give home
care for
the young infant
Advise mother when to
return
immediately
Follow up in 2 day 19

20. •Temperature
between 35.5-
36.4degree Celsius
LOW BODY
TEMPERATURE
Warm the young
infant by skin
contact for 1 hr and
REASSESS
Treat to prevent
low
blood sugar
20

21. Diarrhoea
• ASK:-
• •Does the child have diarrhea?
• • IF YES THEN , FOR HOW LONG?
• LOOK AND FEEL:-
• •Look at the general conditions. Is he/she
• -lethargic or unconscious?
• -restless and irritable?
• •Look for sunken eyes
21

22. Dehydration
22
•Pinch the skin of abdomen ,
and notice how it goes back:
-very slowly( longer than two
seconds)?
-slowly?
-immediately?

23. Classification:
Signs
Two of the
following
signs:
Lethargic or
unconscious
Sunken eyes
Skin goes back
very slowly
Classify
SEVERE
DEHYDRATION
treatment
If infant has low weight or another
severe
classification:
Give first dose of intramuscular
ampicillin
and gentamicin
- Refer URGENTLY to hospital with
mother giving frequent sips of ORS on
theway
- Advise mother to continue breast
feeding
- Advise mother to keep the young
infant warm on the way to the
hospital
OR
If infant does not have low weight or
any other severe classification:
- Give fluid for severe dehydration
(Plan C)
and then refer to
hospital after rehydration
23

24. Advise mother when to
return immediately
Follow up in 5 days if
not
improving
Two of the following
signs for
restless, irritable
sunken eyes
skin pinch goes
back slowly
SOME
DEHYDRATION
Give first dose of
intramuscular
ampicillin and
gentamicin.
Give fluids to treat some
dehydration(PLAN B)
Refer URGENTLY to
hospital with mother
giving frequent oral sips
of ORS.
24

25. •Diarrhea
lasting 14
days
or more
SEVERE
PERSISTENT
DIARRHOEA
Give first dose of intramuscular
ampilicin and gentamicin if infant has
low weight if the young infant has
low weight, dehydration or another
severe classification.
Refer to hospital
Advise to keep the baby warm
Treat to prevent low blood sugar
•Blood in
the stools
SEVERE
DYSENTERY
Give first dose of intramuscular
ampilicin and gentamicin if infant
has low weight if the young infant
has low weight, dehydration or
another severe classification.
Refer to hospital
Advise to keep the baby warm
Treat to prevent low blood sugar 25

26. Feeding problems
• Ask the mother:-
Is there any difficulty in feeding?
Is the infant breastfed?
• If yes - how many times in 24
hours?
Does the infant usually receive any other food or
drinks?
• If yes - how often?
What do you use to feed the infant?
26

27. • Look , Feel:-
Determine weight for age
-Mid Upper Arm Circumference(MUAC)
• MUAC TAPE
27

28. Assess Breast Feeding :-
•Has the infant breastfed in previous hour?
•Is the infant able to attach?
To check attachment , look for:
Chin touching breast
Mouth wide open
Lower lip turned outward
More areola visible above than below .
28

29. Signs of attachment
29

30. • Classify feeding as:
Not able to feed-serious bacterial infection or
severe malnutrition
Feeding problem or low weight for age
No feeding problem
30

31. Immunization Status
• CHECK IMMUNIZATION STATUS:
• IMMUNIZATION SCHEDULE
• Birth - BCG,OPV(0) HepB1
• 6 weeks - DPT1, OPV1,HepB2
31

32. Counsel The Mother
• Advice mother to give home care for the
young infant:
Food and fluids
Breastfeed frequently as often and for as long
as the infant wants.
Make sure the young infant stays warm at all
times.
32

33. sit
Visit
If the infant has
•Local bacterial infection
•Jaundice
•Diarrhea
•Any feeding problem
•Thrush
Return for follow up in
2 days
Low weight for age 14 days
33

34. When To Return Immediately
If the young infant has any of this signs:
• Breastfeeding or drinking poorly
• Becomes sicker
• Develops a fever or feels cold to touch
• Fast breathing
• Difficult breathing
• Yellow palms and soles
• Diarrhoea with blood in stool.
34

35. ASSESS And CLASSIFY THE SICK CHILD
AGE From 2 Months Up To 5 YEARS
• General Danger Signs
ASK:
• Is the child able to drink or breastfeed?
• Does the child vomit everything?
• Has the child had convulsions?
LOOK:
• See if the child is lethargic or unconscious
35

36. Cough or Difficult Breathing
IF YES, ASK:
• For how long?
LOOK, LISTEN, FEEL:
• Count the breaths in one minute.
2-12 months = fast breathing >/= 50/min
12 months-5yrs = fast breathing >/=40/min
• Look for chest indrawing
• Look and listen for stridor
36

37. Classify Cough or Difficult Breathing
•Any general danger
sign or
•Chest indrawing or
•Stridor in calm child.
SEVERE
PNEUMONIA
OR VERY
SEVERE DISEASE
Give first dose of an
appropriate
antibiotic.
•Refer URGENTLY to
hospital.
•Fast breathing PNEUMONIA •Give an appropriate oral
antibiotic
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.
37

38. No signs of
pneumonia
or very severe
disease.
NO PNEUMONIA:
COUGH OR COLD
•If coughing more than 30
days,
refer for assessment.
•Soothe the throat and
relieve the
cough with a safe remedy.
•Advise mother when to
return
38

39. 39
Does the child have diarrhea?
IF YES, ASK:
•For how long?
•Is there blood in the stool?
LOOK, LISTEN, FEEL:
Look at the child’s general condition, is
the child:
Lethargic or unconscious?
Restless or irritable?
Look for sunken eyes
Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
Pinch the skin of the abdomen.
Does it go back:
Very slowly (> than 2 secs)?
Slowly?

40. Classify 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.
40

41. Two of the
following signs:
Restless, irritable
Sunken eyes
Drinks eagerly,
thirsty
Skin pinch goes
back slowly
SOME
DEHYDRATION
Give fluid 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.
Not enough signs
to classify as some
or severe
dehydration.
NO
DEHYDRATION
Give fluid and food to treat diarrhoea at
home (Plan A).
Advise mother when to return
immediately.
Follow-up in 5 days if not improving.
41

42. Fever
• Does the child have FEVER?
IF YES, decide the malaria risk: high or low
THEN ASK:
•For how long?
•If more than 7 days, has fever been present every day?
•Has the child had measles within thelast 3 months?
LOOK AND FEEL:
• Look for runny nose
• Look or feel for stiff neck
42

43. LOOK FOR SIGNS OF MEASLES
has measles now or within the last 3 months
-Rash - Mouth ulcers
-Cough - Pus from eyes
-Runny nose -Clouding of cornea
-Red eyes
43

44. Classification Table For High Malaria
Risk
Any general danger
sign or
•Stiff neck or
• bulging fontanelle
VERY SEVERE
FEBRILE
DISEASE
•Give first dose of an appropriate
antibiotic.
•Treat the child to prevent low blood
sugar.
•Give one dose of paracetamol in clinic
for high fever (38.5° C or above).
•Refer URGENTLY to hospital.
•Fever (by history or
feels hot or
temperature above
37.5
MALARIA Give oral antimalarials for HIGH
RISK MALARIA.
•Give one dose of paracetamol
•Advice mother when to return
immediately
•Follow up in 2 days
.
44

45. Classification Table For Measles
(If Measles Now Or Within The Last 3
Months)
•Any general danger sign
or
•Clouding of cornea or
•Deep or extensive
mouth ulcers.
•Give vitamin A.
•Give first dose of an
appropriate
antibiotic.
•If clouding of the cornea
or pus
draining from the eye,
apply tetracycline
eye ointment.
•Refer URGENTLY to
hospital.
SEVERE
COMPLICATED
MEASLES***
•Give vitamin A.
•Give first dose of an
appropriate
antibiotic.
•If clouding of the cornea
or pus
draining from the eye,
apply tetracycline
eye ointment.
•Refer URGENTLY to
hospital.
45

46. •Pus draining from the
eye or
•Mouth ulcers
MEASLES WITH
EYE OR MOUTH
COMPLICATIONS
***
•Give vitamin A.
•If pus draining from the
eye, treat eye
infection with tetracycline
eye ointment.
•If mouth ulcers, treat with
gentian violet.
•Follow-up in 2 days.
•Measles now or within
the last 3 months.
MEASLES Give vitamin A.
46
*** Other important complications of
measles—pneumonia, stridor, diarrhoea, ear
infection, and malnutrition—are classified in
other tables.

47. Ear Problem
• Does the child have an EAR PROBLEM?
IF YES, ASK
•Is there ear pain?
•Is there ear discharge? If yes, for how long?
LOOK AND FEEL:
• Look and pus draining from the ear
• Feel for tender swelling behind the ear.
47

48. Classification Table For Ear Problem
Tender swelling
behind the ear.
MASTOIDITIS •Give first dose of an appropriate
antibiotic.
•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 an oral antibiotic for 5 days.
•Give paracetamol for pain.
•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.
•No ear pain and No
pus seen draining from
NO EAR
INFECTION
No additional treatment
48

49. Malnutrition and Anemia
CHECK FOR MALNUTRITION AND ANEMIA
LOOK AND FEEL:
• Look for visible severe wasting
• Look for palmar pallor. Is it:
• Severe palmar pallor?
• Some palmar pallor?
• Look for edema of both feet
• Determine weight for age
CLASSIFY NUTRITIONAL STATUS
49

50. Classification Table For Malnutrition
And Anaemia
•Visible severe
wasting or
•Severe palmar
pallor or
•Oedema of both
feet.
SEVERE
MALNUTRITION
OR SEVERE
ANAEMIA
•Give Vitamin A.
•Refer URGENTLY to
hospital.
50

51. •Some
palmar pallor
or
•Very low
weight for
age.
ANAEMIA OR
VERY
LOW WEIGHT
•Assess the feeding
— If feeding problem, follow-up in 5 days.
•If pallor:
— Give iron.
— Give oral antimalarial if high malaria risk.
— Give mebendazole if child is 2 years or older
and has not had a dose in the previous 6
months.
•Advise mother when to return immediately.
•If pallor, follow-up in 14 days.
If very low weight for age, follow-up in 30 days.
•Not very
low weight
for age and
no other
signs or
malnutrition.
NO ANAEMIA
AND
NOT VERY LOW
WEIGHT
•If child is less than 2 years old, assess the
feeding and counsel the mother on feeding.
— If feeding problem, follow-up in 5 days.
•Advise mother when to return immediately
51

52. Immunization Status
IMMUNIZATION SCHEDULE
• Birth - BCG, OPV 0
• 6 weeks - DPT1, OPV1, HepB1
•10 weeks - DPT2,OPV2,HepB2
•14 weeks - DPT3, OPV3,HepB3
•9 months – measles+ vit A
•16-18 months-DPTbooster,OPV
•60 months-DPT
52

53. Counselling a mother or caretaker
• Ask and Listen
• Praise
• Advice
• Check
Essential elements-
• Teach how to give oral drugs
• Teach how to treat local infection
• Teach how to manage breast or nipple problem
• Teach correct positioning and attachment for breastfeeding
• Counsel on other feeding problems
• Advise when to return
• Counsel the mother about her own health
53

54. If t
s: Follow-up Visit Table In The Counsel
The Mother Chartin
PNEUMONIA
DYSENTERY
MALARIA, if fever persists
FEVER—MALARIA UNLIKELY, if fever
persists
MEASLES WITH EYE OR MOUTH
COMPLICATIONS
2 days
PERSISTENT DIARRHOEA ACUTE EAR
INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEM
ANY OTHER ILLNESS, if not improving
5 days
VERY PALOR 14 days
LOW WEIGHT FOR AGE 30 days
54

55. Advise to return immediately
55

56. THANK U
56