Integrated

Management of
Childhood Illness

Integrated Management of Childhood Illness

WHO Regional Office for the Western Pacific/ Child Health
 Causes of 10.5 million deaths among children
< 5 in developing countries, 1999

Pneumonia
19%
One in
every two
child deaths
in perinatal
developing 20% Malnutrition
countries
Diarrhoea
are due to 54%
just five Others 28%
15%
infectious
diseases
and
malnutrition Measles
8%
HIV/AIDS Malaria
3% 7%
Source: EIP/WHO, 1999 data
 Important Elements
for Improving Child Health

• Improve case management of sick children

• Improve nutrition
• Ensure immunization
• Prevent injuries
• Prevent other diseases
• Improve psychosocial support and stimulation
 Too many different pieces…
Appropriate
Case Care seeking Anemia
management
Home
Nutrition care
HIV/AIDS
Drug
Use
New born
Malaria care
Child Follow-up
rights
Health Safe and
system Mothers Supportive
Communication
health Environment
IMCI brings them all together

IMPROVEMENT OF HEALTH SYSTEM

IMPROVEMENT OF CASE MANAGEMENT

FAMILY AND COMMUNITY PRACTICES

CHILD RIGHTS
 IMCI brings it all together

Improving health Strengthening

workers’ skills health system

Improving family
and community
practices
 At the start of a sick child
(2 months to 5 years) consultation

• Ask the mother what the child’s

problems are.
• Determine if this is an initial or follow-
up visit for this problem.
 IMCI Approach
Classification
Focused Assessment
Need to Refer
Danger signs
Main Symptoms
Nutritional status Specific treatment
Immunization status
Other problems Home
management

Counsel & Follow-up Treatment

Counsel caretakers Identify treatment

Follow-up Treat
 Check for general danger signs

Ask:
• Not able to drink or breastfeed,
• Vomits everything,
• Convulsions, or
Look:
• Abnormally sleepy or difficult
to awaken

Need to Refer
(except in severe dehydration)
 Ask about the main symptoms

• Cough or difficulty in breathing

• Diarrhea
• Fever
• Ear problem
 Cough or difficulty in breathing

Ask:
• For how long?
Look:
• Count RR
• Chest indrawing The child
must be calm.
• Stridor
 Any general danger sign or
 Chest indrawing or
 Stridor

SEVERE PNEUMONIA OR
VERY SEVERE DISEASE

 1st dose of antibiotic

 Vitamin A
 Breastfeeding/sugar water
 URGENT REFERRAL
 Fast breathing
2 – 12 months old: ⋝ 50/minute
1 year or older: ⋝ 40/minute

PNEUMONIA

 Antibiotic for 5 days

 Relieve cough with safe remedy
 Advise mother on danger signs
 Follow up in 2 days
 No signs of pneumonia
or a very severe disease

NO PNEUMONIA: COUGH OR COLD

 If cough ⋝ 30 days
 refer to hospital for assessment
 Relieve cough with safe remedy
 Advise mother on danger signs
 Follow up in 5 days if no improvement
Diarrhea: Classify

For dehydration

Persistent diarrhea

Blood in the stool

 Classify for dehydration

2 or more of the following:

 Abnormally sleepy/difficult to wake
 Sunken eyes
 Not able to feed/drinking poorly
 Skin pinch goes back very slowly

SEVERE DEHYDRATION Plan C

 Plan C: To treat dehydration quickly

IV fluid: LRS 100 ml/kg body weight

(in 6 hrs for infants; 3 hrs for children)

NO

IV treatment within 30 minutes

NO

Oresol/NGT
Plan C: To treat dehydration quickly

Oresol/NGT

NO

Oresol p.o.

NO

URGENT REFERRAL
 Classify for dehydration

2 of the following:
 Restless, irritable
 Sunken eyes
 Skin pinch goes back slowly

SOME DEHYDRATION Plan B

Plan B: Treat some dehydration with ORS

Determine the amount (in ml) of Oresol

to be given in 4 hours
= weight of the child (in kg) X 75, or
if weight is unknown, use this chart.

Age 12<mos-2
4 mosyrs 4-12
2-5 yrs
mos
Amount 700-900
200-400 900-1400
400-700
Plan B: Treat some dehydration with ORS

 Show the mother how to give Oresol to

the child: frequent sips from a cup
 If the child vomits, wait for 10 minutes.
Then continue, but more slowly.
 Continue breastfeeding if the child
wants to breastfeed.
 If the child develops puffy eyelids, stop
ORS.
Plan B: Treat some dehydration with ORS

After 4 hours:
 Reassess the child & classify for
dehydration.
 Select appropriate plan.
 Begin feeding the child in the health
center.
 Classify for dehydration

Not enough signs to classify as

SEVERE DEHYDRATION or
SOME DEHYDRATION

NO DEHYDRATION Plan A
 Plan A: Treat diarrhea at home

 Give extra fluid.

Up to 2 yrs 50 – 100 ml after each LBM

2 -4 yrs 100 – 200 ml after each LBM

 Continue feeding.
 Know when to return.
 Persistent diarrhea: 14 days or more

+ Dehydration=severe persistent diarrhea

• Treat dehydration
• Give Vitamin A
• Refer to hospital
 Persistent diarrhea: 14 days or more

No dehydration=persistent diarrhea

• Advise regarding feeding

• Give Vitamin A
• Follow up in 5 days
Blood in the stool = dysentery

• Oral antibiotic for shigella for

5 days
• Follow up in 2 days
Fever: (history/temperature 37.5°C or above)

Malaria risk?

Measles now or w/in last 3 mos

Dengue risk?
 Fever: Ask about malaria risk

• Residing in endemic area?

OR:
• Travel & overnight
stay in endemic area, or w/in past
• Blood transfusion 6 mos
 Malaria risk +

• Blood smear
• Ask: Duration of fever?
Present everyday?
• Look: Stiff neck
Runny nose
Other signs of measles
 Malaria risk +
any general danger sign or stiff neck

Very severe febrile disease/malaria

• Quinine (under med. supervision)

• 1st dose of antibiotic, Paracetamol
• Urgent referral
Malaria risk +, blood smear +
No runny nose, no measles

Malaria

• Oral antimalarial
• Paracetamol
• Follow up in 2 days
• > 7 days fever  hospital for
assessment
 No malaria risk
Any general danger sign or stiff neck

Very severe febrile disease

• 1st dose of antibiotic, Paracetamol

• Urgent referral
 Measles now or w/in last 3 mos
Clouding of cornea or
Deep or extensive mouth ulcers

Severe complicated measles

• 1st dose of antibiotic, Vitamin A

• Urgent referral
Measles now or w/in last 3 mos
Pus draining from the eye or
Mouth ulcers

Measles with eye or

Mouth complications

• Vitamin A
• Tetracycline eye ointment
• Gentian violet
• Follow up in 2 days
Measles now or w/in last 3 mos
No other signs

Measles

• Vitamin A
 If there is Dengue risk

Bleeding gums, nose, in vomitus or

stools
Black vomitus or stools
Persistent abdominal pain
Persistent vomiting
Skin petechiae
Slow capillary refill
No signs, but fever > 3 days 
Tourniquet test
 Any of the danger signs
or + tourniquet test

Severe Dengue hemorrhagic fever

• If skin petechiae, persistent abdominal

pain or vomiting, or + tourniquet test
only signs, give ORS
• Any other signs of bleeding  Plan C
• Urgent referral
• Do not give aspirin
 Ear problem:
tender swelling behind ear

Mastoiditis

• 1st dose of antibiotic

• Paracetamol for pain
• Urgent referral
Ear discharge < 14 days or
Ear pain

Acute ear infection

• Antibiotic for 5 days

• Paracetamol for pain
• Wicking
• Follow up in 5 days
Ear discharge for 14 days or more

Chronic ear infection

• Wicking
• Follow up in 5 days
Visible severe wasting or
Edema on both feet or
Severe palmar pallor

Severe malnutrition or
severe anemia

• Vitamin A
• Urgent referral
 Some palmar pallor or
Very low weight for age

Anemia or very low weight for age

• Assess for feeding problem

• Pallor: iron & Albendazole
• Wt for age very low: Vitamin A