INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

Definition:
 This (an approach to strengthen the provision of comprehensive and essential
health package to children)
 Management process includes:
a. Assessment of the sick child or infant
b. Classify the illness
c. Identify the specific treatment
d. Treat the child
e. Counsel the caretaker
f. Give follow-up care

Features of IMCI:
 not necessarily dependent on the use of sophisticated and expensive
technologies
 a more integrated approach to managing sick children
 move beyond addressing single diseases to addressing the overall health and
well-being of the child
 careful and systematic assessment of common symptoms and specific clinical
signs to guide rational and effective actions
 integrates management of most common childhood problems (pneumonia,
diarrhea, measles, malaria, dengue hemorrhagic fever, malnutrition and anemia,
ear problems)
 includes preventive interventions
 adjusts curative interventions to the capacity and functions of the health system
(evidence-based syndromic approach)
 involves family members and the community in the health care process

Objectives of IMCI:
 Reduce deaths and the frequency and severity of illness and disability among
children
 Contribute to improved growth and development
 This program target children less than 5 years old because this age group bears
the highest burden of deaths from common childhood diseases.
 Careful and systemic assessment of common symptoms and well-selected
specific clinical signs provides sufficient information to guide rational and
effective action.

Components of integrated approach:

 Improvement in the case management skills of health staff through the provision
of locally adapted guidelines on IMCI and activities to promote their use
o standard guidelines
o training (pre-service/in-service)
o follow-up after training
 o role of private providers
 Improvement in the overall health system required for effective management
of childhood illness
o essential drug supply and management
o organization of work in health facilities
o management and supervision
o referral system
 Improvement in family and community healthcare practices.
o for physical growth and mental development
 Breastfeeding
 Complementary feeding
 Micronutrient supplementation
 Psychosocial stimulation
o for disease prevention
 immunization
 handwashing
 sanitary disposal of feces
 use of insecticide-treated bednets
 dengue prevention and control
o for appropriate home care
 continue feeding
 increase fluid intake
 appropriate home treatment
o for seeking care
 Follow health workers advice
 When to seek care
 Prenatal consultation
 Postnatal (postpartum) consultation

5 major killers of children:

1. Diarrhea
2. Acute Respiratory Infection (Pneumonia)
3. Measles
4. Malaria
5. Malnutrition

Principles of Integrated care:

 All sick children must be examined for general Danger Signs which indicate
the need for immediate referral or admission to hospital
 All sick children must be routinely assessed for major symptoms
o For children age 2 months up to 5 years
 Cough
 Diarrhea
 Fever
 Ear Problem
 o For young infants age 1 week up to 2 months
 Bacterial infection
 Diarrhea
 They must be routinely assessed for nutritional status, feeding
problems and other potential problems.
 Treatment procedure for sick children
o IMCI classifications are not necessarily specific diagnosis, but they
indicate what action needs to be taken.

OUTPATIENT MANAGEMENT OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS:

 Assessment of sick children includes:
o history taking and communicating with the caretaker about the child’s
problem
o Checking for general danger signs
o Checking main symptoms
o Checking nutritional status
o Assessing the child’s feeding
o Checking immunization status
o Assessing other problems
 Steps to good communication:
o listen carefully to what the care taker says
o Use words the caretaker understand
o Give the caretaker time to answer questions
o Ask additional questions when the caretaker is not sure about the
answer

IMCI CASE MANAGEMENT

A. Focused Assessment /Assessing the sick child:
 Check for the presence of the general danger signs:
 lethargy or
 unconsciousness
 inability to drink or breastfeed
 vomiting
 convulsions
 If the child has one or more of these signs, he/she must be considered
seriously ill and will almost always need referral
 In order to start treatment for severe illnesses without delay, the child
should be quickly assessed for the most important causes of serious illness
and death (ARI, diarrhea, fever, nutritional status)
 Check for the 4 main symptoms:
 Cough or difficulty in breathing
 Diarrhea
 Fever
 Ear problem
  Check for the nutritional status
 Check the immunization status
 Check for other problems

Checking for the main symptoms:

1. Cough or difficult breathing
o 3 clinical signs
 Respiratory rate
 Lower chest wall indrawing
 Stridor
2. Diarrhea
o Dehydration
o General condition
o Sunken eyes
o Thirst
o Skin elasticity
o Persistent diarrhea
o Dysentery

3. Fever
o Stiff neck
o Risk of malaria and other endemic infections, e.g. dengue hemorrhagic
fever
o Runny nose
o Measles
o Duration of fever (e.g. typhoid fever)

4. Ear problems
 Tender swelling behind the ear
 Ear pain
 Ear discharge or pus (acute or chronic)

Checking for the Nutritional Status, Feeding, and Immunization Status

1. Malnutrition
 Visible severe wasting (marasmus)
 Edema of both feet (kwashiorkor)
 Weight for age
2. Anemia : check for palmar pallor
3. Feeding and breastfeeding
4. Immunization status
 Illness is not a contraindication to immunization; sick children may be
even more in need of protection provided by immunization than well
children. A vaccine’s ability to protect is not diminished in sick children.
  The following are the four common situations that are contraindications
to immunization of sick children:
o Children who are being referred urgently to the hospital should
not be immunized
o Live vaccines (BCG, measles, polio, yellow fever) should not be
given to children with immunodeficiency disease (AIDS) or to
children who are receiving immunosuppressive agents or
radiation.
o DPT2, DPT3 should not be given to children who have had
convulsion or shock within 3 days of a previous dose of DPT
o DPT should not be given to children with recurrent convulsion or
other active neurological disease of the CNS

Assessing other problems

 Address the child’s other complaints and ask questions about the caretaker’s
health
1. Meningitis
2. Sepsis
3. Tubercolosis
4. Conjuctivitis
5. Others

B. Classify the Illness

 IMCI color coding:
o Pink - This is a severe classification. The patient needs urgent
attention and referral or admission for in-patient care.
o Yellow - The child needs an appropriate antibiotic, an oral anti-
malarial or other treatment which can be given in health center.
o Green - The child does not need specific medication/treatment such
as antibiotic. The child can be managed at home by mother or
caretaker.

C. Treatment
 If urgent: referral is needed and possible
o Identify urgent pre-referal treatments
 Needed prior to referral of the child according to classification
o Refer the child
 Explain to the child’s caretaker the need for referral.
 Calm the caretaker’s fears and help resolve any problems.
Write a referral note.
 Give instructions and supplies needed to care for the child on
the way to the hospital
 Identify Treatment
o Identify specific medical treatments and advice
  Give the first dose of oral drugs in the clinic and/or advice the
child’s caretaker.
 Teach the caretaker how to give oral drugs and how to treat
local infections at home.
 If needed, give immunizations.

IMCI essential drugs and supplies that should be available at the health station:
 Appropriate antibiotics
 Quinine
 Vitamin A
 Paracetamol
 Oral antimalarial
 Tetracycline eye ointment
 ORS
 Mebendazole or albendazole
 Iron
 Vaccines
 Gentian violet

D. Counseling/ health education

 Assess the child’s feeding, including breastfeeding practices, and solve
feeding problems, if present.
 Advise about feeding and fluids during illness and about when to return to a
healthy facility.
 Counsel the mother about her own health.

 Feeding recommendations
o Exclusive breastfeeding from birth to at least 6 months
 Breastfeed as often as the child wants, day and night, at least 8
times in 24 hours
 Breastfeed when the child shows signs of hunger:beginning to
fuss, sucking fingers or moving lips
 Do not give other foods or fluids
o 6 months up to 12 months:
 Breastfeed as often as the child wants
 Give adequate amount of lugaw with added oil, mashed
vegetables or beans, steamed tokwa, flaked fish or chiken,
chopped meat, eggyolk, bite sized fruits
 3x/day of breastfeed
 5x/day if not breastfeed
 Give chewable items to eat with fingers, let the child try to feed
himself
E. Follow-up care
 Give follow-up care when the child returns to the clinic and, if necessary, re-
asses the child for new problems.
Overall IMCI Case Management Process
Outpatient
1 - assessment
2 - classification and identification of treatment
3 - referral, treatment or counseling of the child’s
caretaker (depending on the classification identified
4 - follow-up care
Referral Health Facility
1 - emergency triage assessment and treatment
2 - diagnosis, treatment and monitoring of patient progress

COUGH OR DIFFICULT BREATHING

1. Assess
 A child with cough or difficult breathing is assessed for:
o Duration: how long the child has had cough or difficult breathing
o Fast breathing
o Chest indrawing
o Stridor in a calm child (harsh noise made when the child breathes)
2. Classify

Any general danger signs or Severe pneumonia

 Chestclassifications:
3 possible indrawing or
Stridor in a calm child Very severe disease

Fast breathing Pneumonia

No sing of pneumonia or very No pneumonia:

severe disease Cough or cold
o PINK: Severe pneumonia or very severe disease
 Any general danger sign or
 Chest indrawing
 Stridor in a calm child
o YELLOW: Pneumonia
 Fast breathing
o GREEN: No pneumonia: cough or cold
 No sign of pneumonia or very severe disease
 fast breathing is:
o 2-12 months 50 breaths/min or more
o 12mo-5y/o 40 breaths/min or more

DIARRHEA
1. Assess
 How long did the child has had diarrhea
o 14 days or more: persistent diarrhea
 blood in the stool: dysentery
 Signs of dehydration:
o Restlessness
o Irritability
 Look and feel:
o Look at the child’s general condition. Is the child abnormally
sleepy or difficult to awaken? Restless or irritable?
o Look for sunken eyes
o Offer the child fluid. Is the child not able to drink or drinking
poorly? Drinking eagerly, or thirsty?
o Pinch the skin of the abdomen. Does it go back very slowly (longer
than 2 seconds), or slowly?
2. Classify
Two of the following signs: SEVERE DEHYDRATION
1. Abnormally sleepy or difficult to awaken
2. Sunken eyes
3. Not able to drink or drinking poorly
4. Skin pinch goes back very slowly
Two of the following signs: SOME DEHYDRATION
1. restless, irritable
2. Sunken eyes
3. Drinks eagerly, thirsty
4. Skin pinch goes back slowly
Not enough signs to classify as some or severe NO DEHYDRATION
dehydration

Classify persistent diarrhea

Dehydration present SEVERE PERSISTENT >Treat dehydration before referral

DIARRHEA unless the child has another severe
classification
>Give vitamin A
>Refer to hospital
No dehydration PERSISTENT DIARRHEA >Advise the mother on feeding a
child who has persistent diarrhea
 Give vitamin A
 Follow-up in 5 days
 Advise mother when to
return immediately

 Dysentery:
 o A child with diarrhea and blood in the stool
o Caused by Shigella

FEVER
1. Assess and classify Fever
 Malaria
 Measles
 Dengue Hemorrhagic Fever

 A child has the main symptom fever if:

o The child has history of fever, or
o The child feels hot, or
o The child has an axillary temperature of 37.5 or above
 Ask:
o Does the child have fever?
o For how long? If more than 7 days, has the fever been present
everyday?
o Ha the child had measles within the last 3 months?

MANAGEMENT OF THE SICK YOUNG INFANT (1WEEK UP TO 2 MONTHS)

Management Process:
1. assess the young infant
2. classify the illness
3. identify the treatment
4. treat the young infant
5. counsel the mother
6. give follow-up care

1. Assess and classify the sick young infant

 Check for signs of possible bacterial infection. Then classify the young infant
based on the signs found
 Ask about diarrhea. If the child has diarrhea, assess the related signs.
Classify for dehydration
 Check for feeding problem or low weight. Classify feeding
 Check immunization status
 Assess any other problems
 Ask: has the infant had convulsions?
 Look, listen, feel:
 Count breaths in 1 minute
 Repeat count if elevated
 Look for severe chest indrawing
 Look for nasal flaring
 Look and listen for grunting
  Look and feel for bulging fontanel
 Look for pus draining from the ear
 Look at the umbilicus. Is it red or draining pus?
 Measure the temperature
 Look for skin pustules
 See if the infant is abnormally sleepy or difficult to awaken
 Look at the infant’s movement, are they less than normal?

2. CLASSIFY the young infant for possible bacterial infection, IDENTIFY

Treatment and TREAT

SIGNS CLASSIFY AS TREAMENT

Convulsions or POSSIBLE SERIOUS  Give first dose of IM
Fast breathing (60/min or BACTERIAL antibiotic
more) INFECTION  Treat to prevent low
Severe chest indrawing blood sugar
Nasal flaring  Advise the mother
Grunting how to keep the
Bulging fontanel infant warm on the
Pus draining from ear way to the hospital
Umbilicus redness extending to  Refer urgently to the
the skin hospital
Fever or low body temp
Many or severe skin pustules
Abnormally sleepy or difficult to
awaken
Less than normal movement
Red umbilicus or draining pus, LOCAL BACTERIAL  Give appropriate oral
or INFECTION antibiotic for 5 days
 Treat local infection
in the health center
and teach the mother
to treat local
infections at home
 Advise the mother to
give home care for
the young infant
 Follow-up in 2 day
DIARRHEA

2 of the following signs: SEVERE DEHYDRATION  If infant does not have

 Abnormally sleepy POSSIBLE SERIOUS
or difficult to BACTERIAL INFECTION
awaken OR DYSENTERY:
 Sunken eyes  Give fluid for severe
 Skin pinch goes dehydration
back very slowly  If infant also has possible
serious bacterial
infection or dysentery:
 Refer urgently to
hospital with mother
giving frequent sips of
ORS on the way

Two of the ff signs: SOME DEHYDRATION > Give fluid and food for
>restless, irritable some dehydration
Sunken eye > If infant also has
Skin pinch goes back possible serious bacterial
slowly infection or dysentery:
Refer urgently to hospital
with mother giving
frequent sips of ORS on
the way
> Advise mother how to
keep infant warm

Not enough signs to NO DEHYDRATION Give fluid to treat diarrhea

classify as some or severe at home
dehydration

CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

ASK: LOOK, FEEL

 Is there any difficulty feeding? Determine weight for age
Is the infant breastfed? If yes how
many times
in 24 hours
 Does the infant usually receive any
other foods or drinks? If yes, how
 often?
 What do you use to feed the child?

ASSESS BREASTFEEDING
 Four signs of good attachment:
 Chin touching the breast
 Mouth wide open
 Lower lip turned outward
 More areola visible above than below the mouth
 Good positioning:
 Infant’s neck is straight or bent slightly backward
 Infant’s body is turned towards the mother
 Infant’s body is close to the mother, and
 infant’s whole body is supported
 Poor positioning:
 Infant‘s neck is twisted or bent forward
 Infant’s body is turned away from the mother
 Infant’s body is not close to the mother
 Only the infant’s head and neck are supported

3. COUNSELLING ON TREATMENT
 Treat local infections at home:

 To treat skin pustules:

o Wash hands
o Gently wash off pus and crusts with soap and water
o Dry the area
o Wash hands

 To treat umbilical infection:

o Wash hands
o Clean with 70% ethyl alcohol
o Paint with 0.5% gentian violet
o Wash hands

 To treat thrush
 Wash hands
 Wash mouth with clean soft cloth wrapped around the finger and wet
with salt water
 Paint the mouth with 0.25% gentian violet
 Wash hands


4. FOLLOW-UP

IF THE INFANT HAS: WHEN TO FOLLOW-UP
 Local infection  2 days
 Any feeding problems
 Thrush
 low weight for age  14 days
 Breastfeeding or  Follow-up immediately
drinking poorly
 Become sicker
 Develops a fever
 Fast breathing
 Difficult breathing
 Blood in stool
