INTEGRATED

MANAGEMENT OF
CHILDHOOD ILLNESS
IMCI: Overview
◻ A more integrated approach to managing sick
children is needed to achieve better outcomes.
◻ Child health programmes need to move beyond
addressing single diseases to addressing the
overall health and well-being of the child.
◻ Improvements in child health are not necessarily
dependent on the use of sophisticated and
expensive technologies.
IMCI: Overview
◻ During the mid-1990s, the World Health
Organization (WHO), in collaboration with
UNICEF and many other agencies, institutions
and individuals, responded to this challenge by
developing a strategy known as the Integrated
Management of Childhood Illness (IMCI).
IMCI: Overview
◻ The IMCI clinical guidelines target children
less than 5 years old — the age group that
bears the highest burden of deaths from
common childhood diseases .
IMCI: Overview
◻ Careful and systematic assessment of
common symptoms and well-selected specific
clinical signs provide sufficient information to
guide rational and effective actions.
 THE PRINCIPLES OF INTEGRATED CARE

◻ All sick children must be examined 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 (for children age 2 months up to 5
years: cough or difficult breathing, diarrhoea, fever,
ear problems; for young infants age 1 week up to 2
months: bacterial infection and diarrhoea). They must
also be routinely assessed for nutritional and
immunization status, feeding problems, and other
potential problems.
THE PRINCIPLES OF INTEGRATED CARE

◻ Only a limited number of carefully-selected

clinical signs are used, based on evidence of
their sensitivity and specificity to detect
disease. These signs were selected
considering the conditions and realities of
first-level health facilities
THE PRINCIPLES OF INTEGRATED CARE

◻ A combination of individual signs leads to a

child’s classification(s) rather than a
diagnosis. Classification(s) indicate the
severity of condition(s). They call for specific
actions based on whether the child (a) should
be urgently referred to another level of care,
(b) requires specific treatments (such as
antibiotics or antimalarial treatment), or (c)
may be safely managed at home.
 THE PRINCIPLES OF INTEGRATED CARE

◻ The classifications are colour coded:

⬜ “pink” suggests hospital referral or admission,
⬜ “yellow” indicates initiation of treatment, and
⬜ “green” calls for home treatment.
THE PRINCIPLES OF INTEGRATED CARE

◻ The IMCI guidelines address most, but not all, of the

major reasons a sick child is brought to a clinic. A
child returning with chronic problems or less common
illnesses may require special care. The guidelines do
not describe the management of trauma or other
acute emergencies due to accidents or injuries.
◻ IMCI management procedures use a limited number
of essential drugs and encourage active
participation of caretakers in the treatment of
children.
THE PRINCIPLES OF INTEGRATED CARE

◻ An essential component of the IMCI guidelines

is the counselling of caretakers about home
care, including counselling about feeding,
fluids and when to return to a health facility.
◻ The IMCI guidelines recommend case
management procedures based on two age
categories:
⬜ Children age 2 months up to 5 years
⬜ Young infants age 1 week up to 2 months
MANAGEMENT OF
CHILDREN AGE 2
MONTHS UP TO 5
YEARS
APAC Process
General Danger Signs

Lethargy
Unconsciousness

Vomiting Danger Convulsions

Signs

Inability to drink
or breastfeed
General Danger Signs
Is the child lethargic or unconscious
 CLINICAL ASSESSMENT

◻ Three key clinical signs are used to assess a

MAIN sick child with cough or difficult breathing:
SYM ⬜ Respiratory rate, which distinguishes children
PTO who have pneumonia from those who do not;
M: ⬜ Lower chest wall indrawing, which indicates
Coug
severe pneumonia; and
h/Diff
icult ⬜ Stridor, which indicates those with severe
Breat pneumonia who require hospital admission.
hing
 CLINICAL ASSESSMENT

Re
spi Cut-off rates for fast breathing
rat Child’s Age Cut-off Rate for Fast
or Breathing
y 2 months up to 12 50 breaths per minute
months or more
rat 12 months up to 5 40 breaths per minute
e years or more
 CLINICAL ASSESSMENT

Lo ◻ Defined as the inward movement of the bony

we
structure of the chest wall with inspiration, is a
r
ch useful indicator of severe pneumonia.
es ◻ more specific than “intercostal indrawing”
t
wa ◻ should only be considered present if it is
ll consistently present in a calm child.
in ◻ Agitation, a blocked nose or breastfeeding can
dr
aw
all cause temporary chest indrawing.
in
CLINICAL ASSESSMENT
 CLINICAL ASSESSMENT

◻ a harsh noise made when the child inhales

Str (breathes in).
ido ◻ Children who have stridor when calm have
a substantial risk of obstruction and should
r be referred.
◻ Some children with mild croup have stridor
only when crying or agitated.
◻ Sometimes a wheezing noise is heard
when the child exhales (breathes out).
Again:
CLINICAL ASSESSMENT

◻ Three key clinical signs are used to assess a

MAIN sick child with cough or difficult breathing:
SYM ⬜ Respiratory rate, which distinguishes children
PTO who have pneumonia from those who do not;
M: ⬜ Lower chest wall indrawing, which indicates
Coug
severe pneumonia; and
h/Diff
icult ⬜ Stridor, which indicates those with severe
Breat pneumonia who require hospital admission.
hing
 CLASSIFICATION OF COUGH OR DIFFICULT
BREATHING

MAIN
SYM
PTO
M:
Coug
h/Diff
icult
Breat
hing
CLASSIFICATION OF COUGH OR DIFFICULT
BREATHING
 WRITE A REFERRAL NOTE for the
caregiver to carry.

• The name and age of the infant or child

• The date and time of referral
• Description of the child’s problems
• The reason for referral (signs/symptoms for classification)
• Treatment that you have given
• Any other information that the hospital needs to know in order to care
for the
child, such as earlier treatment of the illness or immunizations needed
• Your name and the name of your clinic
Injectable Antibiotic
Give an appropriate oral antibiotic
Vitamin A
 Treatment Procedure
◻ Give an appropriate oral antibiotics for 5
days
◻ Soothe the throat and relieve the cough
with a safe remedy
Pneumonia

◻ Advise mother when to return immediately

◻ Follow up in 3 days
Safe remedy for cough and cold
◻ There is no evidence that commercial cough
and cold remedies are any more effective than
simple home remedies in relieving a cough or
soothing a sore throat.
◻ Suppression of a cough is not desirable
because cough is a physiological reflex to
eliminate lower respiratory tract secretion.
◻ Breastmilk alone is a good soothing remedy.
◻ Tamarind, Calamansi and Ginger
Follow up care
 Treatment Procedure
◻ If wheezing (or disappeared after rapidly acting
bronchodilator) give an inhaled bronchodilator for 5
days
◻ Soothe the throat and relieve the cough with a safe
No Pneumonia:
Cough or colds

remedy
◻ If coughing for more than 14 days or recurrent
wheezing, refer for possible TB or asthma
assessment
◻ Advise mother when to return immediately
◻ Follow-up in 5 days if not improving
◻ The nurse assesses the child with stridor and
lower chest indrawing. What is the
classification of the child?
a. No pneumonia: cough or colds
b. Pneumonia
c. Severe pneumonia or very severe disease
d. dysentery
 Diarrhea
Diarrhoea is the next symptom that should be routinely checked in every
child brought to the clinic. A child with diarrhoea may have three
potentially lethal conditions:
1. acute watery diarrhoea (including cholera)
2. dysentery (bloody diarrhoea)
3. persistent diarrhoea (diarrhoea that lasts more than 14 days).
All children with diarrhoea should be assessed for:
a. signs of dehydration
b. how long the child has had diarrhoea
c. blood in the stool to determine if the child has dysentery.
 CLINICAL ASSESSMENT

◻ All children with diarrhoea should be checked to determine

the duration of diarrhoea, if blood is present in the stool and if
dehydration is present. A number of clinical signs are used to
determine the level of dehydration:
MAIN
⬜ Child’s general condition. Depending on the degree of
SYM
dehydration, a child with diarrhoea may be lethargic or
PTO
unconscious or look restless/irritable.
M:
⬜ Sunken eyes.
Diarr
⬜ Child’s reaction when offered to drink.
hea
⬜ Elasticity of skin. Check elasticity of skin using the skin
pinch test.
Sunken Eyes
The eyes of a dehydrated child may
look sunken. In a severely
malnourished child who is visibly
wasted (that is, who has marasmus),
the eyes may always look sunken,
even if the child is not dehydrated.
Even though the sign “sunken eyes”
is less reliable in a visibly wasted
child, it can still be used to classify
the child's dehydration.
 Child’s reaction when offered to drink

◻ A child is not able to drink if s/he is not able to take fluid in

his/her mouth and swallow it. For example, a child may not
be able to drink because s/he is lethargic or unconscious.
◻ A child is drinking poorly if the child is weak and cannot drink
without help. S/he may be able to swallow only if fluid is put
in his/her mouth.
◻ A child has the sign drinking eagerly, thirsty if it is clear that
the child wants to drink. Notice if the child reaches out for the
cup or spoon when you offer him/her water. When the water
is taken away, see if the child is unhappy because s/he
wants to drink more.
Standard Procedures for Skin Pinch Test

• Locate the area on the child's abdomen

halfway between the umbilicus and the
side of the abdomen; then pinch the skin
using the thumb and first finger.
• The hand should be placed so that when
the skin is pinched, the fold of skin will be
in a line up and down the child's body
and not across the child's body.
• It is important to firmly pick up all of the
layers of skin and the tissue under them
for one second and then release it.
Skin Pinch Test

•When released, the skin pinch goes

back either very slowly (longer than 2
seconds), or slowly (skin stays up even
for a brief instant), or immediately.
•In a child with marasmus (severe
malnutrition), the skin may go back
slowly even if the child is not
dehydrated. In an overweight child, or
a child with oedema, the skin may go
back immediately even if the child is
dehydrated.
Severe Dehydration

Dehyration
Erythromycin
Tetracycline
Some Dehydration

Dehyration
 Dehyration

•Give fluid & food to treat

No Dehydration

diarrhea at home (Plan A)

•Give Zinc supplements
•Advise mother to return
immediately
•Follow up in 5 days if not
improving
Remember

Antibiotics should not be used routinely for

treatment of diarrhoea. Most diarrheal episodes are
caused by agents for which antimicrobials are not
effective, e.g., viruses, or by bacteria that must first
be cultured to determine their sensitivity to
antimicrobials. A culture, however, is costly and
requires several days to receive the test results.
Moreover, most laboratories are unable to detect
many of the important bacterial causes of diarrhea.
Remember

Anti-diarrheal drugs — including anti-motility agents

(e.g., loperamide, diphenoxylate, codeine, tincture of
opium), adsorbents (e.g., kaolin, attapulgite,
smectite), live bacterial cultures (e.g., Lactobacillus,
Streptococcus faecium), and charcoal — do not
provide practical benefits for children with acute
diarrhea, and some may have dangerous side
effects. These drugs should never be given to
children less than 5 years old.
 Diarrhea 14 days or more

◻ Treat dehydration before referral unless child

Severe Persistent Diarrhea

has another sever classification

◻ Give Vitamin A
◻ Refer to hospital
 Diarrhea 14 days or more

◻ Advise mother on feeding a child who has

persistent diarrhea
Persistent Diarrhea

◻ Give Vitamin A
◻ Follow up in 5 days
◻ Advise mother to return immediately
Persistent Diarrhea

Follow up care
 Blood in the Stool
◻ Give ciprofloxacin for 3 days
◻ Follow up in 3 days
◻ Advise mother when to return immediately
Dysentery
 Blood in the Stool

Cotrimoxazole
Dysentery

Nalidixic Acid
 Blood in the Stool: Follow Up Care
Dysentery
 FEVER: CLINICAL ASSESSMENT

Body temperature should be checked in all sick children

History taking
brought to an outpatient clinic. Children are considered to
General danger signs
have
Main fever if their body temperature is above 37.5°C
symptoms
axillary
Cough (38°C
or difficult rectal). In the absence of a thermometer,
breathing
Diarrhea
children are considered to have fever if they feel hot.
Fever
Ear problems
A child presenting
Nutritional status with fever should be assessed for:
Immunization status
Other problems
☑ Stiff neck. A stiff neck may be a sign of meningitis,
☑ cerebral malaria or another very severe febrile disease. If
☑ the child is conscious and alert, check stuffiness by tickling
☑
☑ the feet, asking the child to bend his/her neck to look down
☑ or by very gently bending the child’s head forward. It
◻ should move freely.
◻
◻
 CLINICAL ASSESSMENT

Risk of malaria and other endemic infections. In situations

where routine microscopy is not available or the results may be
delayed, the risk of malaria transmission must be defined. A
high malaria risk setting is defined as a situation in which more
than 5 percent of cases of febrile disease in children age 2 to
59 months are malarial disease. A low malarial risk setting is a
situation where fewer than 5 percent of cases of febrile disease
in children age 2 to 59 months are malarial disease, but in
which the risk is not negligible.
 CLINICAL ASSESSMENT
If other endemic infections with public health importance for children
under 5 are present in the area (e.g., dengue haemorrhagic fever or
relapsing fever), their risk should be also considered. In such situations,
the national health authorities normally adapt the IMCI clinical
guidelines locally.
Runny nose. When malaria risk is low, a child with fever and a runny
nose does not need an antimalarial. This child's fever is probably due to
a common cold.
Duration of fever. Most fevers due to viral illnesses go away within a
few days. A fever that has been present every day for more than five
days can mean that the child has a more severe disease such as
typhoid fever.
 CLINICAL ASSESSMENT

Measles. Considering the high risk of complications

and death due to measles, children with fever should
be assessed for signs of current or previous
measles (within the last three months). Measles
deaths occur from pneumonia and larynigotracheitis
(67 percent), diarrhoea (25 percent), measles alone,
and a few from encephalitis. Other complications
(usually nonfatal) include conjunctivitis, otitis media,
and mouth ulcers. Significant disability can result
from measles including blindness, severe
malnutrition, chronic lung disease (bronchiectasis
and recurrent infection), and neurologic dysfunction
Very Severe Febrile Disease
Malaria
Fever: Malaria Risk
Fever: Malaria Risk
 Fever: Malaria Risk
Malaria
Recommended Tx for Malaria
Fever – Malaria Unlikely

Fever: Malaria Risk

Follow up care
Fever: No Malaria Risk
Fever: Measles
Follow Up Care
 Fever: Dengue Hemorrhagic Fever
Cl
ini
◻ Bleeding from nose or gums
ca ◻ Bleeding in stools or vomitus
l
A ◻ Black stool or vomitus
ss ◻ Skin petechiae
es
s ◻ Cold clammy extremities
m
e ◻ Capillary refill time for more than 3 seconds
nt ◻ Persistent abdominal pain
◻ Torniquet test positive
 Fever: Dengue Hemorrhagic Fever
◻ If persistent vomiting or persistent abdominal
Severe Dengue Hemorrhagic Fever

pain or skin petichiae or positive torniquet test

are the only positive signs, give ORS (Plan B)
◻ If any signs of bleeding is positive, give fluid
rapidly, as in Plan C
◻ Treat the child to prevent low blood sugar
◻ Refer all children urgently to hospital
◻ Do not give aspirin
 Fever: Dengue Hemorrhagic Fever
◻ Advise mother when to return immediately
Follow up in 2 days if fever persists or child
Hemorrhagic Fever Unlikely

shows signs of bleeding

Fever: Dengue

◻ Do not give aspirin

 Ear Problems
Cl
ini
◻ When otoscopy is not available,
History taking
ca look
General danger signs for the following simple
l clinical signs:
Main symptoms
Cough or difficult breathing
A Diarrhea
ss Fever
⬜Ear problems
Tender swelling behind the ear.
es
s The most serious complication of an
Nutritional status
Immunization status
m ear infection is a deep infection in
Other problems
e ☑ the mastoid bone.
☑
nt ☑
☑ ⬜ Ear pain.
☑
☑
☑ ⬜ Ear discharge or pus.
◻
◻
Mastioditis
Acute Otitis Media
Wicking the Ear
Follow Up Care
Malnutrition & Anemia
Malnutrition
Severe Wasting
Kwashiorkor
Edema
Pitting Edema
 MEASURE WEIGHT-FOR-HEIGHT OR
LENGTH

By comparing a child’s weight to his/her height or length,

you can measure how thin the child is. If the weight-for
height or length is low, the child is wasted. This is an
important measurement of acute malnutrition. You have also
learned wasting is an important sign of marasmus.
MEASURE WEIGHT-FOR-HEIGHT OR
LENGTH
MEASURE MUAC (only for children 6–59
months)
MEASURE MUAC (only for children 6–59
months)
Appetite test
Appetite test
 Malnutrition & Anemia
Cl ⬜ Palmar pallor. Although this clinical sign is less
ini
ca specific than many other clinical signs included in
l the IMCI guidelines, it can allow health care
A
ss providers to identify sick children with severe
es anaemia often caused by malaria infection. Where
s
m feasible, the specificity of anemia diagnosis may
e be greatly increased by using a simple laboratory
nt
test (e.g., the Hb test).
Follow Up Care in child w/ Feeding Problem
Pallor
Follow Up Care in Child w/ Pallor
HIV/ AIDS Status
HIV/ AIDS Status
HIV/ AIDS Status
Immunization Status
 Contraindication to immunization
I
m
m
u
ni
za
tio
n
I
m
m
u
ni
za Illness is not a contraindication to
tio immunization. A vaccine’s ability to protect
n
is not diminished in sick children.
 Assess for Other Problems
History taking
General danger signs
Main symptoms
Cough or difficult breathing
Diarrhea
Fever
Ear problems
Nutritional status
Immunization status
Other problems
☑
☑
☑
☑
☑
☑
☑
☑
☑
MANAGEMENT OF
YOUNG INFANTS AGE 1
WEEK UP TO 2 MONTHS
MANAGEMENT OF YOUNG INFANTS
AGE 1 WEEK UP TO 2 MONTHS
◻ While there are similarities in the management
of sick young infants (age 1 week up to 2
months) and children (age 2 months up to 5
years), some clinical signs observed in infants
differ from those in older children.
 WHY ARE YOUNG INFANTS SPECIAL (2
MONTHS & YOUNGER)?

1. They become ill and die very quickly from serious

bacterial infections. Severe infections are the most
common serious illness during first 2 months of life.
2. Special risk for low birth weight infants: Infants
under 2.5 kilograms at birth are low weight. Infections
are particularly dangerous in low birth weight infants.
This means the infant had low weight at birth, due
either to poor growth in the womb or to prematurity (being born
early).
 WHY ARE YOUNG INFANTS SPECIAL (2
MONTHS & YOUNGER)?

3.Infants often show only general signs when seriously

ill, such as difficulty in feeding, reduced movements, fever or
low body temperature.

4.Newborn infants are often sick from conditions

related to labour and delivery. Newborns with any of these
conditions require immediate attention. Some infants are
premature, or born before 37 weeks of pregnancy.
 Assessment includes the following steps

◻ Checking for possible bacterial infection;

◻ Assessing if the young infant has diarrhea;
◻ Checking for feeding problems or low weight;
◻ Checking the young infant’s immunization
status;
◻ Assessing other problems.
 BACTERIAL INFECTION
◻ While the signs of pneumonia and other serious bacterial
infections cannot be easily distinguished in this age group,
it is recommended that all sick young infants be assessed
first for signs of possible bacterial infection.
◻ CLINICAL ASSESSMENT
◻ Many clinical signs point to possible bacterial infection in
sick young infants. The most informative and easy to
check signs are:
⬜ Convulsions (as part of the current illness). Assess the
same as for older children.
⬜ Fast breathing. 60 breaths per minute is the cut-off rate to
identify fast breathing in this age group.
BACTERIAL INFECTION
⬜ Severe Chest indrawing. Mild chest indrawing is normal in a young infant
because of softness of the chest wall. Severe chest indrawing is very deep
and easy to see. It is a sign of pneumonia or other serious bacterial infection
in a young infant.
⬜ Nasal flaring (when an infant breathes in) and grunting (when an infant
breathes out) are an indication of troubled breathing and possible pneumonia.
⬜ A bulging fontanel (when an infant is not crying), skin pustules, umbilical
redness or pus draining from the ear are other signs that indicate possible
bacterial infection.
⬜ Lethargy or unconsciousness, or less than normal movement also
indicate a serious condition.
⬜ Temperature (fever or hypothermia) may equally indicate bacterial
infection. Fever (axillary temperature more than 37.5°C or rectal temperature
more than 38°C) is uncommon in the first two months of life. Fever in a young
infant may indicate a serious bacterial infection, and may be the only sign of a
serious bacterial infection. Young infants can also respond to infection by
dropping their body temperature to below 35.5°C (36°C rectal).
Nasal Flaring
Cotrimoxazole
Amoxycillin
Treatment of Local Infections
Diarrhea
◻ CLINICAL ASSESSMENT AND
CLASSIFICATION OF DIARRHOEA
◻ Assessment, classification and management of
diarrhoea in sick young infants are similar to those
in older children. However, assessing thirst by
offering a drink is not reliable, so “drinking poorly”
is not used as a sign for the classification of
dehydration. In addition, all young infants with
persistent diarrhoea or blood in the stool should
be referred to the hospital, rather than managed
as outpatients.
 Feeding Problems or Low Weight
Cl ◻ Determine weight for age. Assess the same as for older
ini children.
ca
◻ Assessment of feeding.
l
⬜ (1) breastfeeding frequency and night feeds;
A
⬜ (2) types of complimentary foods or fluids, frequency of feeding
ss
and whether feeding is active or not;
es
⬜ (3) feeding patterns during this illness.
s
m ◻ If an infant has difficulty feeding, or is breastfed less than 8
e times in 24 hours, or taking other foods or drinks, or low weight
nt for age, then breastfeeding should be assessed. Assessment of
breastfeeding in young infants includes checking if the infant is
able to attach, if the infant is suckling effectively (slow, deep
sucks, with some pausing), and if there are ulcers or white
patches in the mouth (thrush).
Weight for Age
Breast feeding
Breastfeeding: Signs of Good Attachment
•Chin touching breast;
•Mouth wide open;
•Lower lip turned outward; and
•More areola visible above than below the mouth.
Feeding Problems or Low Weight
Feeding Problems or Low Weight
Feeding Problems or Low Weight
Immunization Status

Age Vaccine
Immunization Birth BCG
Schedule
6 weeks DPT-1, OPV-1, Hepa B-1
Assess for Other Problems
THE END
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