IMNCI

FOR EMERGENCY NURSING

STUDENTS

By Beletech F ( BSC,MSC)

05/23/2021 1
 Introduction to
IMNCI
Integrated Management New
I
born and Child hood llnesses

05/23/2021 2
 Objective
After the end of this unit the students should be able to:
• Define IMNCI
• Identify the commonest child health problems
that can be managed by IMNCI
• Recognize the steps of the case mgt process
• Select the appropriate case mgt charts
• Describe the steps of immediate newborn care.
• List the new born and infant danger signs

05/23/2021 3
 Objective …
• Assess and classify sick young and older infants
• Recognize the general danger signs in sick children.
• Use or fill-in the recording form correctly
• Identify treatments or measures.
• Treat the sick child or young infant
• Counsel mothers or significant others about the
disease, management, when to return and prevention.
• Give follow up care.
• Demonstrate skills in referring sick child to the hospital.

05/23/2021 4
 Child health
INTRODUCTION
• Under 15 years constitute 44.7% of the
population
• Of which 40% are under five and 8% are
under one year.
• Neonatal mortality rate 37/1000 live birth
• Infant mortality rate is 59/1000 live births
• Under five mortality rate 88/1000 live births
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 Child health…
• 1/20 born alive die in their first month of life

• 1/10 die before reaching their 1st birth day

• 1/6 die before reaching their fifth birthday

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 Child health…
• More than 70% of these deaths are due to the five
diseases.
– Pneumonia 28.9%
– Malaria 21.6%
– Diarrhea 12%
– Measles 5%
– 60% of these deaths are associated with malnutrition
– HIV/AIDS 11%

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 IMNCI

WHAT IS IMNCI?
• IMNCI is a strategy to reduce morbidity &
mortality associated with the major illness.

• Is the integrated strategy that

combines and links together existing
child health programs.

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 IMNCI
• Action-oriented CLASSIFICATIONS , rather than
EXACT DIAGNOSES are used.
• Using FEW CLINICAL SIGNS as possible which
health workers of diverse background can be
trained to recognize.
• The IMNCI guidelines rely on detection of cases
based on SIMPLE CLINICAL SIGNS without
laboratory tests and offer EMPIRIC TREATMENT.

05/23/2021 9
 What are under-fives dying of?
(excluding neonatal causes of death)

• Pneumonia
•
•
•
•
Malaria
Diarrhoea
Measles
HIV/AIDS
} ~ 50%

Malnutrition contributes to more than half of all under-five deaths

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 What are neonates dying of?

• Preterm births
•
•
•
•
Severe infection
Asphyxia
Congenital anomalies
Tetanus
} ~ 75%

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 SOLUTIONS EXIST
• A mix of community and facility-based
interventions

• A mix of integrated child health approaches

• Integrated management of neonatal and

child hood illnesses is proven tool

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 Delivery strategies/tools exist

MPS
Skilled care

Infant feeding Vital vaccines

NUT IMNCI EPI

Combating Antibiotics for

diarrhea pneumonia

RBM Combating Combating HIV

malaria HIV
MPS – Making Pregnancy Safer
NUT - Nutrition
RBM – Roll Back Malaria
EPI – Expanded Programme on Immunization
05/23/2021 13
 IMNCI Cont…
• There are feasible & effective ways that Health
Workers can prevent most of these deaths.
• WHO/UNICEF suggested the management of these
illnesses in as set of integrated (combined) guidelines
instead of separate guidelines for each illness.
• There are also important relation ship between the
illnesses. E.g. repeated diarrhea episodes often lead
to malnutrition.

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 IMNCI Cont…

• There fore, Effective case mgt needs to consider all

of the child symptoms.
• Case mgt can be effective only the families bring
their sick children to trained H.W on timely.
• If a family waits to bring a child to a clinic until the
child is extremely sick, the child is more likely to die
from the illness.
• Therefore, teaching families to bring the sick child
to the clinic immediately is an important part of the
case mgt process.

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 THE INTEGRATED CASE MANAGEMENT
PROCESS
• Integrated case management relies on case detection
using simple clinical signs and research-based
empirical treatment.
• The signs are based on expert clinical opinion and
research results.
• The IMNCI describes how to care for a child who is
brought to the health institution with an illness, or
for a scheduled follow-up visit to check the child's
progress.

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 The case mgt process

• The case mgt process is presented on series of charts

which shows the sequence of steps.
The charts described the following steps.
1. Assess the child or young infant: - assess a child by
checking first for general danger signs (or possible
series bacterial infection in a young infant)
Assess means taking Hx & P/E.
2. Classify the illness: means select category or
classification based on the major symptoms, or classify
a child’s illnesses using a colour-coded triage system.

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3. Identify Rx=After classifying all conditions,
identify specific treatments for the child.
 Selecting & classification on the chart is
sufficient to identify Rx.

4.Treat the child:- Provide practical treatment

instructions, including teaching the caretaker
how to give oral drugs, how to feed and give
fluids during illness, and how to treat local
infections at home.

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5. Counsel the mother.
Assess feeding, including assesm’t of breastfeeding
practices, and counsel to solve any feeding problems
found.

Telling her about foods & fluids to give the child &
to bring the child back to the clinic.

6. Give follow up care: -

When a child is brought back to the clinic as requested,
give follow-up care and, if necessary, reassess the
child for new problems.
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 Case mgt process…
• The case management process is presented on
two different sets of charts:
one for children age 2 months up to five
years, and
one for infant age birth up to 2 months.

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 SELECTING THE APPROPRIATE CASE
MANAGEMENT CHARTS
FOR ALL SICK CHILDREN age birth up to 5 years who are brought to
the clinic:

ASK THE CHILD’S AGE

IF the child is IF the child is

from birth up to 2 from 2 months up to
months 5 years

USE THE CHARTS:

USE THE CHART: •ASSESS AND CLASSIFY
ASSESS, CLASSIFY AND THE SICK CHILD
TREAT THE SICK YOUNG •TREAT THE CHILD
INFANT •COUNSEL THE MOTHER

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USING THE CASE MANAGEMENT CHARTS AND CASE RECORDING FORMS

The IMNCI case management charts and recording

forms guide you through the following steps:
• Assess the sick child or sick young infant
• Classify the illness
• Identify treatment
• Treat the child or young infant
• Counsel the mother
• Give follow-up care
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 THE LEGEND

A CLASSIFICATION THAT NEEDS URGENT

RED

REFERRAL AFTER FIRST DOSE OF

APPROPRIATE ANTIBIOTIC

A CLASSIFICATION THAT NEEDS TREAMENT AT

YELLOW

HOME, ANY HEALTH INSTITUTION AND HEALTH

EDUCATION

A CLASSIFICATION THAT NEEDS HEALTH

GREEN

PROMOTION & EDUCATION

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 IMNCI
Colour Coded Case Management Strategy

• RED CLASSIFICATION: Child needs Drugs & inpatient

care –Mostly serious infections

• YELLOW CLASSIFICATION: Child needs specific

treatment, (e.g. antibiotics, anti-malarial, ORT) for
Mild infections can be Provided at home / community
level

• GREEN CLASSIFICATION: Child needs no medicine,

advise home care

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 Newborn danger signs
• Breathing ≤ 30 or ≥ 60 breaths per minute, grunting,
severe chest indrawing, blue tongue & lips, or gasping
• Unable to suck or sucking poorly
• Feels cold to touch or axillary temperature < 35°C
• Feels hot to touch or axillary temperature ≥ 37.5°C
• Red swollen eyelids and pus discharge from the eyes
• Convulsion
• Jaundice /yellow skin - at age < 24 hours or > 2 weeks
- Involving soles and palms
• Pale, bleeding
• Vomiting, no stool, swollen abdomen
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 Assess and Classify
The Sick Young Infant
Age Birth Up to 2
Months:
05/23/2021 26
 LEARNING OBJECTIVES
* Assess and classify a young infant for birth asphyxia. 
* Assess & classify for birth wt. and gestational age. 
* Assess and classify a young infant for possible
bacterial infection and jaundice. 
* Assessing and classifying a young infant with
diarrhea.
* Assess and classify a young infant for HIV infection. 
* Checking for a feeding problem or low weight,
assessing breastfeeding and classifying feeding. 
* Checking immunization status. 
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 YOUNG INFANT
• Young infants have special characteristics
• They can become sick and die very quickly from
serious bacterial infections.
• They frequently have only general signs such as
few movements, fever, or low body temperature.
• Mild chest indrawing is normal in young infants.
• For these reasons, you will assess, classify and
treat the young infant somewhat differently than
an older infant or young child.

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 Assess & classify for birth asphyxia.

-Asses for birth asphyxia if you are attending delivery or

if baby is brought immediately after birth.
Assess
-If not breathing:
- Gasping: the attempts to make some effort to breath
with irregular & slow breathing movements.
- Count breathing: normal breathing rate of the new
born is from 30-60 beat/min.
Classify: there are two possible classifications
- Birth asphyxia
- No birth asphyxia

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Signs Classify Treatment
If any of the Start resuscitation
following - position the new born supine with
sign: neck slightly extend.
- not - clear the mouth & nose with gauze
breathing or clean cloth.

BIRTH ASPHYXIA
- gasping - ventilate with appropriate size
- breathing mask & self inflating bag
less than 30 - If the resuscitation is successful
per minute continue giving immediate new
born care
- if the baby is having irregular
breathing after 20 minutes
resuscitation; refer urgently to
hospital.
- Monitor continuously for 6 hrs.
- follow after 12hrs, 3days & 6weeks

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 Give immediate new born
- strong cry care
- breathing - cord care

NO BIRTH ASPHYXIA
more than - Apply chlohexidine RT
30b/m for seven days
- eye care
- vitamin K
- initiate skin to skin contact
- initiate exclusive breast
feeding
- advice the mother when to
return
- follow after 6hrs; 3days, &
6 weeks
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 Assess & classify for birth weight & Gestational age/G.A

- Assess for Birth weight & Gestational age :

if you are attending delivery or brought to you with in 7
days after birth.
Assess
- Ask the Gestational age /duration of pregnancy in wks, if
not possible use weight to classify the new born.
Classify
There are 3 possible classifications
- Very low birth weight & or very preterm
- Low birth weight & or pre term
- Low birth weight & or pre term
- Normal weight & or term.

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 Classify for birth weight & Gestational age…
cont…
Signs Classify as Treatment
-Give first dose of I.M
Weight VERY LOW Ampicillin & Gentamycin
< 1500gm or BIRTH - continue feeding with
Gestational WEIGHT expressed breast milk
age < 32 wks AND /OR - continue Kangaroo mother
VERY Care
PRETERM - Give vitamin K 1mg I.M on
anterior mid thigh ,0.5 if
VLBW/VPT
- refer urgently to hospital.

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 Classify for birth wt. & Gestational age cont…

Weight LOW -kangaroo mother care

1500 to BIRTH -counsel on optimal breast
<2500gm or WEIGHT feeding
Gestational AND/OR -counsel mother/family on
age PRETERM prevention of infection
32-37 wks -give vitamin K 1mg I.M on
Y anterior mid thigh
-provide follow up visits at age
6 hrs 2 days & then every
week for 6weeks
-advice the mother when to
return immediately

05/23/2021 34
 Classify for birth wt. & Gestational age cont…
- counsel on optimal breast
Weight feeding
>2500gm or -counsel mother/family on
NORMAL WEIGHT
Gestational prevention of infection
age > 37 AND/OR -provide three follow up visits
wks TERM at the age 6- 24hrs, 3days &
6weeks.
-Give vitamin K 1mg I.M on
anterior mid thigh
-advice the mother when to
return immediately

05/23/2021 35
 Assess & classify the sick young infant for possible bacterial infection &
jaundice.

- The young infant must be calm & may be sleep while

you assess the first 3 signs, i.e. count breathing,
chest in drawing & grunting.
• Ask the family what the young infant’s problems
are.
- determine if this is an initial or follow up visits
for this problem.

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 Check for possible bacterial infection & jaundice..

Ask:
has the infant had convulsion?
is there any difficulty of feeding?/ check by offering
breast feeding (B/F)
- Look: count the breaths in one minute.
If the 1st count is 60 breaths or more repeat count
- Look for chest in drawing: when the infant breath in.

05/23/2021 37
 Check for possible bacterial infection… con’t…
Look & Listen for grunting.
- Grunting= is the soft, short sounds a young infant
makes when breathing out.
Look at the umbilicus: is red or draining pus?
- There may be some redness around the umbilicus or
the umbilicus may be draining pus.
- Measure temperature/ or feel for fever or low body
temperature.
Fever - axillary To greater or equal to 37.5 0c.
Low body To - b/n 35.5 & 36.4 0c

05/23/2021 38
 possible bacterial infection …Cont…

Look for skin pustules:

- examine the skin on the entire body
Skin pustules are red spots or blisters when
contains pus.

05/23/2021 39
 possible bacterial infection …Cont…
• Look at the young infant’s movements; are
they less than normal?
- A wake young infant will normally move his
arms or legs or turns his head several times in a
minute.
- Does the infant moves only when stimulated?
- Does not move even when stimulated.
• Look for jaundice: yellow discoloration of the
skin.

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 Assess & classify the sick young infant for possible
bacterial infection & jaundice.

Signs Classify as Treatment

- not feeding well -Give first dose of I.M

ERIOUS BACTERIAL INFECTION OR

or Ampicillin & Gentamycin
- convulsion/con - warm the young infant by
vulsing now skin to skin contact if To
- fast less than 36.5oc ( or feels
ERY SEVERE DISEASE

breathing/60b/ cold touch) while arranging

m or referral
- sever chest in
drawing

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 Classify possible bacterial infection &
jaundice…Con…
-grunting or - advice the mother

SSIBLE SERIOUS BACTERIAL INFECTION OR

-fever(38oc or above or how to keep the
feels hot) or
young infant warm
-Body temperature
<35.5oc or feels cold) or on the way to

VERY SEVERE DISEASE

-movement only when hospital
stimulated or no - refer urgently to
movement even hospital
stimulated

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 Classify possible bacterial infection &
jaundice…Con…
„ Give twice daily
· Red umbilicus

BACTERIAL
Amoxicillin for 5 days

INFECTION
or draining pus „ Teach the mother to

LOCAL
or treat local infections at
· Skin pustules home
„ Advise mother when to
return immediately
„ Follow-up in 2 days

 
- None of the signs - Advice the mother
UNLIKELY

of possible serious to give home care

bacterial infection for the young
or local bacterial infant.
infection.
ION

05/23/2021 43
 Objectives
After the end of this unit the students should be able to:
• Assess and classify a young infant for jaundice
• Differentiate physiological and pathological jaundice
• Assess, classify and manage young infant with diarrhea.
• Perform skin pinch and decide DHN status in diarrhea pt
• Assess and classify a young infant for HIV.
• Checking for a feeding problem or low weight
• list the 4 good positioning and 4 attachments.
• Check immunization status of young infants.

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 Classify possible bacterial infection…con’t…
- palms - Treat to prevent low blood
and Or sugar
soles - warm the young infant by skin
yellow or to skin contact if To less than
- age JAUNDICE 36.5oc ( or feels cold touch)
SEVERE

<24hrs or while arranging referral

- age - advice the mother how to keep
14days or the young infant warm on the
more way to hospital
- Refer urgently to hospital

05/23/2021 45
 Classify possible bacterial infection con’t…

- Advice the mother to

Only give home care
skin or - Advise the mother
JAUNDICE
eyes when to return
yellow. - Palms and soles appear
Infants yellow.
age 24 hr - Follow up in 2 days
to 14
days

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 Assess Diarrhea
Young infant with diarrhea is assessed for:
- How long the child has had diarrhea
- Blood in the stool to determine if the young infant
has dysentery
- Signs of dehydration.
Ask: does the young infant have diarrhea?
- If the answer is no, you don’t need to assess the child
further for signs to diarrhea.
- If yes; assess the child for signs of DHN, dysentery &
persistent diarrhea.

05/23/2021 47
 Assess Diarrhea…
Check for signs of DHN:
- Restless & irritable
- If DHN continues the infants spontaneous
& stimulated movement will decreased and
becomes lethargy.
- As the child's body loses fluids, the eyes
may be look sunken.
- When pinched, the skin will go back
slowly or very slowly (>2 sec).

05/23/2021 48
 Cont…
Classify Diarrhea
- Sever DHN - Persistent diarrhea
- Some DHN - Dysentery
- No DHN

05/23/2021 49
 Con…
Signs Classify Treatment
as
Two of the following -Give the first dose of
signs I.M Ampicillin and
- movement only Gentamycin
-If infant has another

SEVERE
when stimulated or severe classification:

DHN
no movement even Refer URGENTLY with
stimulated mother giving frequent
- sunken eyes sips of ORS
- skin pinch goes -Advise mother to
back very slowly continue BF
Plan C ?????????

05/23/2021 50
 Give fluid, Zinc supplement & food
Two of the Con…
for some DHN (plan- B??????)
following signs - If the child has severe

SOME DHN
- Restless, classification:
irritable . Refer urgently to hospital with
- sunken eyes mother giving frequent sips of
ORS on the way
- skin pinch goes - Continue B/F
back slowly - Advise the mother when to return
immediately.
- Follow up for “5” day
No enough sign to -Give Fluid, Zinc supplement & food
to treat diarrhea ( plan – A)
classify as some -Advise the mother when to return
NO DHN

or sever immediately
dehydration -Follow up in 5 days if not improving

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 Con…
Diarrhea - Give the first dose of
lasting SEVER IM Ampicilline Or
14 days PERSISTENT Gentamycin
or more DIARRHEA - Treat to prevent low
blood sugar
- Advice how to keep
infant warm on the
way to the hospital
- Refer to hospital

05/23/2021 52
 Con…
-Give the first dose of
Blood I.M Ampicillin or
in the Dysentery Gentamycin
stool -Treat to prevent low
blood sugar.
-Advice how to keep
infant warm on the way
to the hospital
-Refer to hospital

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 Assess for HIV infection

Ask: - has the mother or the child have positive HIV

test?
- If the child has had an HIV test, determine whether
the test was an Antibody test or a PCR test.
Positive HIV test
• HIV infection diagnosed by serological & virological
tests.
• Serological is anti body test, from the mother pass
on to the child & in some instances does not
disappear until the child is 18 months of age.

05/23/2021 NB: PCR(Polymerase chain reaction) 54

 Con…
 This means that a positive antibody test in children
under the age of 18 months is not reliable & does
not confirm that the child is truly HIV infected.
 On the other hand, virological tests, such as PCR
test directly detect HIV in the blood.
 PCR tests can there fore detect HIV infection in the
child before the child is 18 months old.

05/23/2021 55
 Con…
SIGN CLASSIFY AS TREATMENT

- Give cotrimoxazole
Positive PCR CONFIRMED prophylaxis from 6wks
test in the HIV of age.
young INFECTION - Refer for ARV
infant - Assess feeding &
counsel as necessary
- Advice the mother on
home care
- Follow up in 14dys

05/23/2021 56
 Con…
- Mother HIV - Assess feeding &
positive OR POSSIBLE counsel as necessary
HIV - Give cotrimoxazole
- Infant has
INFECTION prophylaxis from 6wks
positive HIV (HIV EXPOSED) of age
antibody test - Confirm HIV status as
soon as possible using
PCR
- Follow up in 14dys

Negative HIV HIV - Advice the mother to

test in the INFECTION give home care for the
UNLIKELY young infant
mother or the
child

05/23/2021 57
 Check for feeding problem or low weight

•Adequate feeding is essential for growth & dev’t.

•Poor feeding during infancy can have lifelong effects.
•The best way to feed a young infant is to breastfeed
exclusively.

•EBF means that the infant takes only breast milk, and
no additional food, water or other fluids. (Medicines
and vitamins are exceptions.)

05/23/2021 58
 Check for feeding problem or low weight..

• The recommendation is that the young infant

be breastfed as often and for as long as the
infant wants, day and night. This should be a
minimum of 8 times or more times in 24
hours.

05/23/2021 59
 Check for feeding problem or low weight..

Ask about feeding & determine wt. for age.

Ask if there is any difficulty of feeding.
- is the infant B/F, if yes for how long?
- Do you empty one breast before switching to the
other?
- Do you increase frequency of B/F during illness?
- Does the infant receive any other foods or drinks?
- What do you use to feed the infant? / Cup, bottle
or other.

05/23/2021 60
 Check for feeding problem…
Determine weight for age
use wt. for age chart to determine if the young infant
is low wt. for age.
- For young infant you should use the low wt. for age
line, instead of very low wt. for age.
Assess breast feeding
- If the infant is exclusively breast feed with out
difficulty & is not low wt. for age, there is no need to
assess B/F.
- If the infant is not breast feed at all, do not assess
B/F.
05/23/2021 61
 low wt for
age

Very low
wt for age

05/23/2021 62
 Check for feeding problem…
- If the infant has serious problem requiring urgent referral to
hospital do not assess B/F.
If an infant
- has any difficulty of feeding
- is breast feeding less than 8 times in 24hrs
- is the mother switching the breast frequently
- Breast feeding not increased during illness
- is taking any other foods or drinks, or
- is low wt. for age &
- has no indications to refer urgently to hospital assess
breast feeding.
05/23/2021 63
 Cont….
Assess breast feeding

- has the infant B/F in the previous hr?

- If the infant has not feed in the previous hr ask the
mother to put her infant to breast, observe the
breast feeding for 4 minutes.
- is the infant well positioned?
looks for the sign of good positioning (not well
positioned, good positioned)
- is the infant able to attach? (No attach at all,
not well attached, good attachment)

05/23/2021 64
 GOOD
POSITIONING
- Infant’s head and body
straight
- Facing her breast
- Infant’s body close to her
body
-Supporting the infant’s
whole body
- all of these signs should be
present if the positioning is good
GOOD
ATTACHMENT
- Chin touching the breast
- Mouth wide open
- Lower lip turned outward
-More areola visible above
than below the mouth
-all of these signs should be
present if the attachment is good

05/23/2021 65
• A baby well attached A baby poorly attached
to his mother's breast to his mother's breast

05/23/2021 66
 Classification of feeding problem
SIGN CASSIFY TREATMENT
AS
If any of the -Advise the mother to breast feed
following as often & for as long as the
- Not well infant wants, day & night
FEEDING PROBLEM OR
positioned - if not well attached or not
or suckling effectively, teach
- Not well LOW WEIGHT correct positioning &
attached to attachment
breast or - If breast feeding less than 8
- Not suckling times in 24hrs, advise to increase
effectively frequency of feeding
or - empty one breast completely
- Less than 8 before switching to the other
breast feeds - .
in 24hrs or - .
Y - .
05/23/2021 67
 Classification of feeding problem Con…
-Switching the -increase the frequency of
breast frequently breast feeding during & after

FEEDING PROBLEM OR
or illness

LOW WEIGHT
-Not increasing -If receiving other foods or
frequency of drinks counsel mother about
breast feeding breast feeding more, reducing
during illness or other foods or drinks & using a
cup
-If not breast feed at all, refer
for breast feeding counseling.
…

05/23/2021 68
 Classification of feeding problem Con…
-Receive other -Advice about correctly
foods or drinks or preparing breast milk
-The mother not substitutes & using a cup

FEEDING PROBLEM
breast feeding at -If thrush, teach the mother

LOW WEIGHT
all or to treat thrush at home
-Low weight for -Advise the mother to give
age or home care
OR
-Thrush( ulcers or -Follow up any feeding
white patches in problem or thrush in 2 days.
mouth) -Follow up low weight for age
in 14days.

05/23/2021 69
 Classification of feeding problem Con…
Not low -Advise mother to give

NO FEEDING PROBLEM
weight for home care
age & no -Praise the mother for
other sign of feeding the infant well
in adequate
feeding

05/23/2021 70
 HOW TO CHECK THE YOUNG INFANT'S IMMUNIZATION STATUS

• The vaccine that should be given to Y/I are

 BCG and polio zero at birth
 OPV, DPT, Hib, Hep B, PCV, and ROTA 1 at the age of 6
weeks

 Remember that you should not give OPV 0 to an

infant who is more than 14 days old. Therefore, if an
infant has NOT received OPV 0 by the time he is 15
days old, you should wait to give OPV1 until s/he is 6
weeks old.
05/23/2021 71
 THE YOUNG INFANT CASE RECORDING FORM

05/23/2021 72
 Assess and Classify
The Sick child
Age 2 Months Up to 5 yrs

05/23/2021 73
 LEARNING OBJECTIVES
After the end of this session the students will be able to:
 Identify the presence or absence of general danger sign
in older children
 List the four main symptoms
 Assess and classify cough and difficulty of breathing. 
 Assessing and classifying diarrhea in children.
 Assessing and classifying fever in children.

05/23/2021 74
 2 Months – 5 years sick children
This age group of children are usually assessed
by : -
 1. Checking the presence or absence of
general danger signs

05/23/2021 75
 2 Months – 5 years sick children..
2. Ask the four main symptoms
Cough or difficult breathing,
Diarrhoea,
Fever, and
Ear problem.

05/23/2021 76
 Main symptoms of 450 sick children

92.5 %
82.5%
100
90
80
70
45%
60
50
40
30
20 8.4%
10
0
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 IMNCI
Frequency of presenting complaints of 450 children
(as volunteered by mothers)
Fever
Cough Covered by
Diarrhea IMNCI
Ear problems (87 %)
Skin lesions
Abdominal pain
Eye discharge
Not covered by IMNCI
Dental problems
Neck swelling (13%)
Gen. swelling
Anorexia
Rectal prolapse
Headaches
Not recorded

-10
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10 30 50 70
78
• For any sick child age 2 mth – 5yrs

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 Top part of the case recording form for
2mth -5 yrs

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 Classify COUGH or DIFFICULT BREATHING

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05/23/2021 82
After checking the general danger sign and asking the presence or absence of
cough then we need to ask does the child have diarrhea?

Does the child have diarrhea?

IF YES, ASK LOOKAND FEEL
For how long? -Look at the child general
condition. is the child:
Is there blood -Lethargic or Unconscious?
in the stool ? -Restlessness or irritable
-Look for sunken eye
- offer the child fluid. is the child:
-not able to drinking or drinking
poorly ?
-Drinking – eagerly, thirsty?
- pinch the skin of abdomen, does it
go back very slowly (longer
than 2 second, or slowly).

05/23/2021 83
• If the mother says the child does not have diarrhea

Then ASK about the next main symptoms:

fever, and ear problem.

• Diarrhoea occurs when stools contain more water than

normal. Diarrhoea is also called loose or watery stools. It is
common in children, especially those between 6 months and 2
years of age. It is more common in babies under 6 months who
are drinking cow's milk or infant formulas. Frequent passing of
normal stools is not diarrhoea.

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 Skin pinch technique

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 HOW TO CLASSIFY DIARRHOEA

• DHN all children with diarrhoea are classified

for dehydration
• PERSISTANT if the child has had diarrhoea for
14 days or more, classify the child for
persistent diarrhoea
• DYSENTERY if the child has blood in the stool,
classify the child for dysentery.

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 Classify Dehydration (DHN)

They are “3” possible classification DHN

1. Severe DHN
2.Some DHN
3. No DHN

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 Classification of DHN
Assess Classify -Identify Rx
Two of the -If the child has no other
following signs sever classification
-Lethargic or -Given fluid for sever

Sever DHN
unconscious DHN ( plan-C ???) or
-Sunken eye -If the child also has
-Not able to another sever classification:
drink or -Refer urgently to hospital
drinking with mother giving frequent
poorly sips of ORS on the way.
-Skin pinch -Advise mother to continue
goes back breast feeding.
very slowly
05/23/2021 88
 Classification of DHN Cont…
Two of the following -Give fluid, Zinc supplement
signs & food for some DHN
(plan- B)
- Restless,

Some DHN
- If the child has sever
irritable classification:
- Sunken eye . Refer urgently to hospital
- Drinks eagerly, with mother giving frequent
thirsty sips of ORS on the way
- Skin pinch - Advise the mother to
continue B/F
goes back - Advise the mother when to
slowly return immediately.
- Follow up for “5” day if not
improving

05/23/2021 89
 Classification of DHN Cont…
- No enough -Give Fluid ,Zinc supplement &
sign to classify food to treat diarrhea ( plan – A)
some or severe -Advise the mother when to
NO DHN
DHN return immediately
-Follow up in 5 days if not
improving
- If confirmed/ suspected
symptomatic HIV, follow up in 2
days if not improving

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 Classify Persistent Diarrhea
• If the diarrhea lasts 14 days or more classify
for persistent diarrhea.
Two classifications
1. Severe persistent diarrhea if some or severe
DHN present
2. Persistent diarrhea if no some or severe DHN
present.

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 Classify Persistent Diarrhea con’t…
DHN Severe Treat DHN before
present -persistent referral if the child has
diarrhea no severe disease
classification
Refer to hospital
Vit – A
supplementation
No DHN Persistent Advise the mother
diarrhea on feeding a child
Follow up for in 05
day
Give vit – A
05/23/2021 92
 Classify dysentery
III. Dysentery: Diarrhea with blood in the stool,
with or with out mucous.
• If the child has blood in the stool classify for
dysentery
-Treat for 05 days
Blood Dysentery with oral antibiotic
in the (Ciprofloxacillin)
stool - Follow up for 2
days

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 Assess and classify FEVER
• DOES THE CHILD HAVE FEVER? (by history or
feels hot or temperature 37.5 0C or above)
IF YES: 
• Decide Malaria Risk: high or low or no
• if “Low or no” malaria risk, then ask: 
 Has the child travelled outside this area during the
previous 2 weeks?
 If yes, has he been to a malarious area?

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Then ask Look and feel
• For how long? • Look or feel for stiff neck
• If more than 7 days, has fever• Look or feel for bulging
been present every day? fontanels (< 1year old)
• Has the child had measles • Look for runny nose
within the last 3 months? • Look for signs of MEASLES
 
Generalized rash and one of
these: cough, runny nose, or
red eyes

If the child has Look for mouth ulcers

Are they deep and extensive?
measles now or Look for pus draining from the eye.
within the last 3 months: Look for clouding of the cornea.
Look for mouth ulcers
Are they deep and extensive?
Look for pus draining from the eye.
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 Any general danger
sign, OR
Classification
 Stiff neck, OR
 Bulging fontanels (< 1
yr)
Positive blood film/RDT, OR
 If blood film/RDT not available, any
fever
(by history, or feels hot, or temp ≥
37.5ºC )
RDT negative, OR
 Blood film negative
 Other cause of fever present
05/23/2021
FEBRILE Give first dose Artesunate or Quinine for severe malaria
 Give first dose of IV/IM Ampicillin and Gentamycin
DISEASE for high/low
 Treat the childmalaria
to prevent low risk
blood sugar
 Give Paracetamol in health facility for high fever (≥38.5°C)
 Refer URGENTLY to hospital
Treat with Artemeter-Lumefantrine for P. falcip. or mixed or no
confirmatory test done
 Treat with Chloroquine for confirmed P. vivax
MALARIA  Give Paracetamol in health facility for high fever (38.5°C or above)
 Give an appropriate antibiotic for identified bacterial cause of
fever
 Advise mother when to return immediately
 Follow-up in 2 days if fever persists
 If fever is present every day for more than 7 days, refer for
assessment
FEVER or No
MALARIA  Give one dose of Paracetamol in health facility for high fever
(≥38.5°C)
 Give an appropriate antibiotic for identified bacterial cause of
fever
 Advise mother when to return immediately
 Follow-up in 2 days if fever persists
 If fever is present every day for more than 7 days, refer for
assessment
96
 Classification of no malaria risk/no travel to malarious area

VERY
 Any general danger sign, OR SEVERE
Give first dose of IV/IM Ampicillin and
 Stiff neck, OR FEBRILE Gentamycin
 Bulging fontanels DISEASE  Treat the child to prevent low blood
sugar
(< 1 year of age)  Give Paracetamol in health facility for
high fever (≥38.5°C)
 Refer URGENTLY to hospital

FEVER Give one dose of Paracetamol in health

 Any fever facility for high fever (≥38.5°C)
 Give an appropriate antibiotic for
identified bacterial cause of fever
 Advise mother when to return
immediately
 Follow-up in 2 days if fever persists
 If fever is present every day for more
than 7 days refer for assessment

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 what is measles??

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 Classification table for measles
(if measles now or within the last 3 months).
 Any general  Give vitamin A therapeutic dose.
danger sign or  Give first dose of an appropriate
SEVERE antibiotic.
 Clouding of COMPLICATED  If clouding of the cornea or pus
cornea or MEASLES draining from the eye, apply
 Deep or extensive tetracycline eye ointment.
 Refer URGENTLY to hospital.
mouth ulcers.
 Give vitamin A, therapeutic dose..
 Pus draining MEASLES WITH  If pus draining from the eye, treat
eye infection with tetracycline eye
from the eye or EYE OR MOUTH ointment.
COMPLICATIONS  If mouth ulcers, treat with gentian
 Mouth ulcers
violet.
 Follow-up in 2 days.
 Measles now or MEASLES  Give vitamin A, therapeutic dose.
within the last 3  Advise when to return immediately
months
05/23/2021 99
 Assess and classify EAR PROBLEM

• Ask if the child has ear problem

IF YES, ASK: LOOK AND FEEL:
 Is there ear pain? -Look for pus draining from the ear
 Is there ear discharge? -Feel for tender swelling behind the ear

If yes, for how long?

 

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 Classification table for ear problem.
 Tender swelling behind
the ear.
 Pus is seen draining from the
ear and discharge is reported
for less than 14 days, OR
 Ear pain.
 Pus is seen draining from the
ear and
discharge is reported for 14
days or more.
 No ear pain and No
pus seen draining from the ear.
05/23/2021
 Give first dose of an appropriate
antibiotic.
MASTOIDITIS  Give first dose of paracetamol for
pain.
 Refer URGENTLY to hospital.
 Give an oral amoxacillin twice
daily for 5 days.
ACUTE EAR  Give paracetamol for pain.
INFECTION  Dry the ear by wicking.
 Follow-up in 5 days.
 Dry the ear by wicking.
 Treat with topical quinolones
CHRONIC eardrops for 2 weeks
EAR  Follow-up in 5 days.
INFECTION
NO EAR
INFECTION No additional treatment.
101
 • Then CHECK for malnutrition and anaemia, HIV infection,
immunization status and other problems.

05/23/2021 102
 CLASSIFY NUTRITIONAL STATUS AND ANEMIA

Every day,
on average more than
26,000 children under
the age of five die
around the world,
mostly from
preventable causes.
Nearly all of them live
in the developing
world.
05/23/2021 103
 CLASSIFY NUTRITIONAL STATUS INFANT LESS THAN 6 MONTHS
COMPLICATED

WFL <-3Z score, and SEVERE ACUTE

MALNUTRITION
► Give first dose of Ampicillin and Gentamycin IM
► Treat the child to prevent Low Blood Sugar
► Advise mother on the need of referral
presence of complications
OR ► Refer Urgently to Hospital
 Oedema of both feet

UNCOMPLICATED
WFL < -3Z score AND no SEVERE ACUTE Counsel on breast feeding and care
complications MALNUTRITION ► Undertake appropriate counseling and feeding advise in cases where a child is orphaned
AND with no other option for breastfeeding
 No oedema of both feet ► Assess for TB infection (Refer table on page 32)*

MODERATE ACUTE
WFL ≥ -3Z to < -2Z score, MALNUTRITION ► Assess feeding and advise the mother on feeding
AND ► Assess for TB infection (Refer table on page 32)*
 No oedema of both feet ► Follow up in 5 days if feeding problem
► Follow up in 30 days
NO ACUTE
MALNUTRITION Assess feeding and advise the mother on feeding
WFL ≥ -2Z score
► Follow up in 5 days if feeding problem
AND
► If no feeding problem-praise the mother
 No oedema of both feet

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• .

05/23/2021 105
 Classification table for anaemia
SEVERE  Give vitamin A
 Severe palmar
ANAEMIA  Refer URGENTLY to hospital
pallor
 Give iron
 Some palmar  Give oral antimalarial if high malaria risk.
pallor
ANAEMIA
 Give mebendazole if child is 12 months or older
and has not had a dose in the previous 6 months.
 Advise mother when to return immediately.
 Follow-u in 14 days.
 No pallor NO  no additional treatment

ANEMIA  Give feedig recomendation

05/23/2021 106
• .

05/23/2021 107
05/23/2021 108
 IMMUNIZATION STATUS
AGE VACCINE

Birth BCG OPV-0

IMMUNIZATION SCHEDULE:

6 weeks DPT1-HepB1-Hib1, Rota1, PCV1 OPV-1

,
DPT2-HepB2-Hib2 Rota2, PCV2
10 weeks OPV-2

DPT3-HepB3-Hib3, PCV3
14 weeks OPV-3
Measles
9 months Vitamin A

05/23/2021 109
 OBSERVE contraindications to immunization

There are only three situations at present that are

contraindications to immunization:
• Do not give BCG to a child known to have
SYMPTOMATIC HIV INFECTION.
• Do not give DPT2-HepB2-Hib2 or DPT3-HepB3-Hib3 to
a child who has had convulsions or shock within 3 days
of the most recent dose.
• Do not give DPT-HepB-Hib to a child with recurrent
convulsions or another active neurological disease of
the central nervous system.
05/23/2021 110
 Immunization …
• Children with diarrhoea who are due for OPV
should receive a dose of OPV (oral polio
vaccine) during this visit. However, do not
count the dose. The child should return when
the next dose of OPV is due for an extra dose
of OPV.
• In all other situations, here is a good rule to
follow: There are no contraindications to
immunization of a sick child if the child is well
enough to go home.
05/23/2021 111
 FINALLY WE HAVE TO:
•  ASSESS OTHER PROBLEMS
• COUNSEL THE MOTHER ABOUT HER OWN
HEALTH

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05/23/2021 113
 Peace 4 all of U!
05/23/2021 114