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

Integrated Management of Childhood Illness (IMCI) as a key strategy for improving child health

Management of sick children

Nutrition

Immunization

Other disease Prevention Promotion of Growth and Development

Integrated Management of Childhood illness ( IMCI )

IMCI: Overview
Careful and systematic assessment of common symptoms and well-selected specific clinical signs provide sufficient information to guide rational and effective actions.

INTERVENTIONS

CURATIVE
ARI Diarrhea Malaria Measles Dengue Malnutrition EAR Infection Meningitis, Sepsis

PREVENTIVE Immunization Nutrition Counseling Breastfeeding Support Vitamin A Supplementation Deworming

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 check for nutritional and

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 firstlevel health facilities

THE PRINCIPLES OF INTEGRATED CARE

A combination of individual signs leads to a childs 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

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:
Sick child age 2 months up to 5 years (2MOS UP TO 4YRS 11MOS 29DAYS) Young infants age 1 week up to 2 months(7DAYS 1MO 29DAYS)

Management of Children age 2 months up to 5 years

erral Facility and at Home ild From Age 2 Months up to 5 Years

OUTPATIENT HEALTH FACILITY

Check for DANGER SIGNS Convulsions Lethargy/Unconsciousnes s Inability to Drink/Breastfeed Vomiting

Assess MAIN SYMPTOMS Cough/Difficulty Breathing Diarrhea Fever Ear Problems

Assess NUTRITION and IMMUNIZATION STATUS and POTENTIAL FEEDING PROBLEMS

Check for OTHER PROBLEMS

CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to Color-Coded Treatment Charts

PINK Urgent Referral

OUTPATIENT HEALTH FACILITY Prereferral Treatments Advise Parents Refer Child

PINK Urgent Referral

REFERRAL FACILITY Emergency Triage and Treatment (ETAT) Diagnosis Treatment Monitoring and Followup

YELLOW Treatment at Outpatient Health Facility OUTPATIENT HEALTH FACILITY Treat Local Infection Give Oral Drugs Advise and Teach Caretaker Follow-up

GREEN Home Management

HOME

Caretaker is counselled on how to: Give oral drugs Treat local infections at home Continue feeding When to return immediatel y Follow-up

OUTPATIENT HEALTH FACILITY y Taking

OUTPATIENT HEALTH FACILITY

Check for DANGER SIGNS Unable to drink or breastfeed Vomiting Convulsions Abnormally sleepy

Assess MAIN SYMPTOMS Cough/Difficulty Breathing Diarrhea Fever Ear Problems

Check NUTRITION and IMMUNIZATION STATUS and POTENTIAL FEEDING PROBLEMS

Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to Color-Coded Treatment Charts

History Taking
The steps to good History taking communication are : General danger signs
Main symptoms Cough or difficult breathing Diarrhea Fever Ear problems Nutritional status Immunization status Other problems

Listen carefully to what the caretaker says. Use words the caretaker understands. Give the caretaker time to answer questions. Ask additional questions when the caretaker is not sure about the answer.

OUTPATIENT HEALTH FACILITY

Check for DANGER SIGNS Convulsions Lethargy/Unconsciou sness Inability to Drink/Breastfeed Vomiting

History taking General danger signs Main symptoms Cough or difficult breathing Diarrhea Fever Ear problems Nutritional status Immunization status Other problems

Assess MAIN SYMPTOMS Cough/Difficulty Breathing Diarrhea Fever Ear Problems

Assess NUTRITION and IMMUNIZATION STATUS and POTENTIAL FEEDING PROBLEMS

Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to Color-Coded Treatment Charts

General Danger Signs

Unable to drink or breastfeed

Convulsions

Vomiting Danger Signs

Abnormally Sleepy Difficult to Awaken

CHECK FOR GENERAL DANGER SIGNS

IS THE CHILD ABLE TO DRINK OR BREASTFEED? Too weak to drink Not able to suck or swallow when offered a drink or breast milk Ask the mother what happens when she offers the child something to drink Clear the nostrils if they are blocked

CHECK FOR GENERAL DANGER SIGNS

DOES THE CHILD VOMIT EVERYTIME HE OR SHE TAKES IN? - Ask the mother how often the child vomits - Ask if the child vomits each time he or she swallows foods or fluids - Ask the mother to offer the child a drink and see if the child vomits

CHECK FOR GENERAL DANGER SIGNS

HAS THE CHILD HAD CONVULSION? - Ask the mother regarding loss of consciousness or may not be able to respond to spoken direction or handling - Ask if the childs arm and legs stiffens because the muscles are contracting - Use words such as jerky movements, spasms, fits - Ask if there is fever at the height of

CHECK FOR GENERAL DANGER SIGNS

SEE IF THE CHILD IS ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN - Is the child drowsy and does not show interest? - If the child doesnt look at mothers face if she talks - If the child doesnt respond if touched, shaken or spoken to

OUTPATIENT HEALTH FACILITY

Check for DANGER SIGNS Convulsions Lethargy/Unconsciou sness Inability to Drink/Breastfeed Vomiting

Assess MAIN SYMPTOMS Cough/Difficulty Breathing History taking Diarrhea General danger signs Fever Ear Problems Main symptoms

Assess MAIN SYMPTOMS Cough/Difficulty Breathing Diarrhea Fever Ear Problems

Cough or difficult breathing Diarrhea Fever Ear problems Nutritional status Immunization status Other problems

Assess NUTRITION and IMMUNIZATION STATUS and POTENTIAL FEEDING PROBLEMS

Check for OTHER PROBLEMS CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to Color-Coded Treatment Charts

Component of IMCIs main symptoms are the following, except:

a.Diarrhea b.Fever c.Malnutrition d.Ear problem

CLINICAL ASSESSMENT
Three key clinical signs are used to assess a sick child with cough or difficult breathing:
Respiratory rate, which distinguishes children who have pneumonia from those who do not; Lower chest wall indrawing, which indicates severe pneumonia; and Stridor, which indicates those with severe pneumonia who require

MAIN SYMPTOM: Cough/Difficult Breathing

CLINICAL ASSESSMENT

Respiratory rate

Cut-off rates for fast breathing

Childs Age 2 months up to 12 months 12 months up to 5 years Cut-off Rate for Fast Breathing 50 breaths per minute or more 40 breaths per minute or more

CLINICAL ASSESSMENT
Defined as the inward movement of the bony structure of the chest wall with inspiration, is a useful indicator of severe pneumonia. more specific than intercostal indrawing should only be considered present if it is consistently present in a calm child. Agitation, a blocked nose or

Lower Chest Wall Indrawing

CLINICAL ASSESSMENT

CLINICAL ASSESSMENT
a harsh noise made when the child inhales (breathes in). Children who have stridor when calm have a substantial risk of obstruction and should be referred. Some children with mild croup have stridor only when crying or agitated. Sometimes a wheezing noise is heard when the child exhales

Stridor

Again:

CLINICAL ASSESSMENT
Three key clinical signs are used to assess a sick child with cough or difficult breathing:
Respiratory rate, which distinguishes children who have pneumonia from those who do not; Lower chest wall indrawing, which indicates severe pneumonia; and Stridor, which indicates those with severe pneumonia who require

MAIN SYMPTOM: Cough/Difficult Breathing

Y M P T O M : C o u g h / D ifficu lt B re a th in g

CLASSIFICATION OF COUGH OR DIFFICULT BREATHING

Any general danger sign No signs of or pneumonia or or Chest indrawing very Fast severe breathing Stridor indisease calm child

severe pneumonia

very severe disease

no pneumonia: or pneumoniacold cough or

CLASSIFICATION OF COUGH OR DIFFICULT BREATHING

-Give first dose of Cotrimoxazole -Give Vitamin A -Treat the child to prevent low blood sugar -Refer Urgently to the hospital -

Treatment Procedure
Give the first dose of an appropriate antibiotics Give Vitamin A Treat the child to prevent low blood sugar Refer URGENTLY to hospital

Very Severe Disease

Severe Pneumonia

or

Treatment Procedure
Give first dose of an appropriate antibiotic.
Two recommended choices are cotrimoxazole and amoxicillin. If the child cannot take an oral antibiotic (children in shock or those who are vomiting incessantly or are unconscious), give the first dose of intramuscular chloramphenicol (40 mg/kg). Options for an intramuscular
Very Severe Disease Severe Pneumonia

or

Give an appropriate oral antibiotic

For pneumonia, acute ear infection, very severe disease, mastoiditis 1st line

Cotrimoxazole Amoxycillin

2nd line

Give Vitamin T REATMENT A

- Give one dose in the health center

SUPPLEMENTATION - Give one dose in the health center if : - Child is nine mos of age or older , AND - Child has not received a dose of Vitamin A in the past 6 mos .
VITAMIN A CAPSULES

AGE 6 months up to12 months 12 months up to 5 years

200 , 000 IU 1 / 2 capsule 1 capsule

If the child is difficult to awaken or unconscious , start IV infusion Give 5ml/kg of 10% dextrose solution (D10) over a few minutes Or give 1ml/kg of 50% (D50) by slow push