INTEGRATED

MANAGEMENT OF
CHILDHOOD ILLNESS
(IMCI)
Maryjan B. Gutierrez, RN
INTRODUCTION
• Gold standard by the World Health Organization (WHO) to address
the a) mortality and b) morbidity
• Strategy patterned to research
• Infant to 5 y/o
• International program designed by WHO in partnership with UNICEF
• Adapted by ADPCN, PMA and APSOM
INTRODUCTION
• IMCI is a major strategy for child survival, healthy growth and
development and is based on the combined delivery of essential
interventions at community, health facility and health systems levels.
• Includes prevention and curative
• Aims to reduce morbidity and mortality cases due to common
childhood illness caused by 5 preventable and treatable conditions
namely: pneumonia, diarrhea, malaria, measles and malnutrition
OBJECTIVES
• Reduce death and frequency and severity of illness and disability and
• Contribute to improved growth and development
COMPONENTS
• Improving case management skills of health workers
• Improving overall health systems
• Improving family and community health practices
A. General D.
B. Main C. Age
Danger Nursing
Symptoms Bracket
Sign Process
A. General D.
B. Main C. Age
Danger Nursing
Symptoms Bracket
Sign Process
A. General D.
B. Main C. Age
Danger Nursing
Symptoms Bracket
Sign Process
A. General D.
B. Main C. Age
Danger Nursing
Symptoms Bracket
Sign Process
 What’s the color?

Color Coding Classification Place Person

Green Mild Home Parents/S.O
Yellow Moderate RHU MW/RN
Pink Severe Hospital MHO –
Municipal
Health Officer
(MHO)
 What’s the color?

Color Coding Classification Place Person

Green Mild Home Parents/S.O
Yellow Moderate RHU MW/RN
Pink Severe Hospital MHO –
Municipal
Health Officer
(MHO)
 What’s the color?

Color Coding Classification Place Person

Green Mild Home Parents/S.O
Yellow Moderate RHU MW/RN
Pink Severe Hospital MHO –
Municipal
Health Officer
(MHO)
A. GENERAL DANGER SIGNS
C
U
V
A
B. Symptoms
1 – Cough/Difficulty Breathing
2 – Diarrhea
4 main symptoms
3 – Fever
4 – Ear infection
5 – Malnutrition & Anemia
6 – HIV; others
7 – Immunization
8 – Feeding problem
C. Age Bracket (IMCI)

<2 months

2 – 5 years old
REFER!!
D. NURSING PROCESS

A
C
T
General Danger Signs
Very Severe Disease
• Any General Danger Signs
- Give Diazepam now
- Refer URGENTLY
- Quickly complete Assessment
- Give sugar Water
200 mL Clean Water
+ 4 tsp of sugar
- Keep the patient Warm
- Give any Pre-referral
1. Coughing/Difficulty Breathing

Severe Pneumonia or Very Severe Disease

• General Danger Signs - Refer urgently
• Stridor - Antibiotic: Amoxicillin
1. Coughing/Difficulty Breathing
Pneumonia
• Fast breathing - IF with wheezing – give oral salbutamol for 5
days
Parameters: - IF with chest indrawing in HIV exposed – 1st
dose of Amoxicillin and refer
<2 months = 60 breaths and up - IF coughing more than 2 weeks or 14 days or
2-12 months = 50 breaths and up
1-5 years = 40 breaths and up recurrent wheeze – Refer for possible TB or
asthma
Example: - FF: 3 days
1 ½ years old – 59 bpm - Antibiotic: Amoxicillin for 5 days
8 months – 45 bpm - Return immediately
1 month – 60 bpm - Soothe the throat & relieve the cough (Safe
remedy)
B-SLK:
1. Coughing/Difficulty Breathing
Cough or colds
• Not enough signs to allow classification - IF with wheezing – give oral salbutamol for 5
days
- IF coughing more than 2 weeks or 14 days or

recurrent wheeze – Refer for possible TB or

asthma
- FF: 5 days
- Return immediately
- Soothe the throat & relieve the cough (Safe
remedy)
B-SLK:
2. Diarrhea (6)

Diarrhea Dehydration
Severe Persistent Diarrhea Severe Dehydration

Persistent Diarrhea Some Dehydration

Dysentery No Dehydration
2. Diarrhea
Severe Dehydration
Two of the following signs:
• Lethargic or Unconscious
• Sunken Eyes
• Drinks Poorly
• Skin goes back very slowly
• Unable to drink or breastfeed
A. If no other severe classification, initiate plan C.
Give fluid for severe dehydration
OR
B. If with another severe classification: Refer the child
to the hospital with sips of ORS
- If the child is 2 years old & above & there’s
epidemic of cholera – Tetracycline
- Encourage the mother to BF the infant/child
Sips of ORS:
Home made content:
1 Liter – Water
1 tsp – Salt
8 tsp - Sugar
2. Diarrhea
Some Dehydration
Two of the following signs: A. If no other severe classification, initiate plan
• Restless, irritable B. (FFOM)
• Sunken eyes OR
• Drinks eagerly, thirsty B. If with another severe classification: Refer
• Skin goes back slowly urgently with frequent sips of ORS

- Encourage the mother to breastfeed the child

- Advice the mother when to return immediately
- FF: 5 days
2. Diarrhea

No Dehydration
• Not enough signs to allow - Plan A: Give food, fluid, ORS, MTV
classification (For 2 weeks)
- Advise when to return immediately
- FF: 5 days
What is Plan C?
Treat the dehydration quickly:

1. IVF resuscitation
2. Oral resuscitation (5 mL/kg/hr)
3. NGT resuscitation (30-50 mL of sugar water)
What is Plan C?
Age Bracket Intensive Maintenance Total
30 mL/kg 70 mL/kg
Up to 1 year 1 hour 5 hours 6 hours
1 – 5 year 30 minutes 2.5 hours 3 hours
Sample
1. 9 months – 10 kg
2. 2 years old – 15 kg
What is Plan B? FFOM @ the RHU (w/in
4hrs)
Constant: 75 mL/kg
Age Bracket Less than 4 4 - 12 1-2 2-5
months
Weight Less than 6 6 – 10 kg 10 - 12 kg 12 – 19 kg
kg
Amt. in mL 200-450 450-800 800-960 960-1600
Sample
Given (Months)
1. 3 months
2. 9 months
3. 1 ½ years old

Given (With weight):

4. 3 months 5kg
5. 9 months 9.8 kg
6. 1 ½ months 11.5 kg
What is Plan A? FFOM @ Home
There are 4 rules in treatment:

1. Encourage the mother to breastfeed the child

What is Plan A?
There are 4 rules in treatment:

2. Know when to return

What is Plan A?
There are 4 rules in treatment:

3. Zinc supplementation

Age Bracket Syrup Tablet

(20mg/5mL) (20mg/tab)
Up to 6 months 2.5 mL ½ tab/10 mg
6 months and 5 mL 1 tab/20 mg
above
What is Plan A?
There are 4 rules in treatment:

4. Additional fluid intake

2. Diarrhea

Severe Persistent Diarrhea

• Diarrhea more than 14 days - Treat the dehydration before
• Dehydration is present referral
- Vitamin A
2. Diarrhea

Persistent Diarrhea
• Diarrhea more than 14 days - Give Vitamin A and MTV (14 days)
• Dehydration is NOT present - Advise in feeding the child
- Return Immediately
- FF: 5 days
2. Diarrhea

Dysentery
• Blood in the stool - Ciprofloxacin 3 days
- Advise when to return immediately
- FF: 3 days
3. FEVER (10)

• Chills
Malaria (5) • Profuse Sweating

• Cough, Coryza, Conjunctivitis

Measles (3) • Rashes, Runny nose, Red Eyes

• Skin petechiae
Dengue (2) • Bleeding
3. FEVER (Malaria)

Malaria

Residence on Overnight Stay in

Blood Transfusion
Malaria-risk Area Malaria – Risk Area
3. FEVER (Malaria-risk area)
Very Severe Febrile Disease/Malaria
• Any of the General Danger Signs - Paracetamol (38.5 C)
(GDS) - Arthemeter & Lumefantrine
• Stiff neck - Sugar Water
- Quinine
- Refer
3. FEVER (Malaria-risk area)
Malaria
• (+) Malarial Test - Paracetamol (38.5 C and above)
- Arthemeter
- Lumefantrine
- FF: 3 days
- Return immediately
- Fever is more than 7 days; refer urgently
(Meningitis & Japanese Encephalitis)
- Antibiotic for identified bacterial cause of
fever
3. FEVER (Malaria-risk area)
Fever No Malaria
• (-) Malaria test - Paracetamol
• (+) Other cause of fever - FF 3 days
- Return immediately
- Fever is more than 7 days: refer
urgently (Meningitis & Japanese
Encephalitis)
- Antibiotic for identified bacterial cause
of fever
3. FEVER (Low Malaria-risk area)

Very Severe Febrile Disease

• Any of the General Danger Signs - Paracetamol
(GDS) - Amoxicillin
• Stiff neck - Refer
- Sugar water
3. FEVER (Low Malaria-risk area)
Fever
• (+) Fever - Paracetamol
• (-) GDS - FF 3 days
• (-) Stiff neck - Return immediately
- Fever is more than 7 days: refer
urgently (Meningitis & Japanese
Encephalitis)
- Antibiotic for identified bacterial cause
of fever
3. FEVER (Measles)
Severe Complicated Measles
• Any of the General Danger Signs - Paracetamol
(GDS) - Amoxicillin
• Clouding of the cornea - Tetracycline @ both eyes (Clouding of
• Deep & extensive mouth ulcers the cornea and pus draining)
- Vitamin A
- Refer
3. FEVER (Measles)
Measles with Eye or Mouth Complication (MEMC)
• Pus seen draining from the eyes - Paracetamol
• Mouth ulcers (Non deep/Non - Vitamin A
extensive) - Return
- Tetracycline
- Gentian violet
- FF: 3 days
3. FEVER (Measles)

Measles
• Now or the last 3 months - Vitamin A
- Return
3. FEVER (Dengue)
Severe Dengue Hemorrhagic Fever
A. (+) Bleeding; Nose & Gums; Melena IVF, Paracetamol, Refer
B. Persistent abdominal pain Paracetamol
Cold & Clammy Skin ORS
Persistent headache Refer
Fever Do not give Aspirin
Poor Capillary Refill
3. FEVER (Dengue)
Dengue Hemorrhagic Fever Unlikely
(+) Fever - Paracetamol
- Avoid aspirin
- Return
- FF: 3 days
4. Ear infection

Mastoiditis
• Tender swelling behind the ear - Refer
- Amoxicillin
- Paracetamol (pain)
4. Ear infection

Acute Ear Infection

• Pus seen draining from the ear less - Paracetamol
than 14 days - Amoxicillin for 5 days
• (+) Pain - Wicking
- FF: 5 days
4. Ear infection

Chronic Ear Infection

• Pus seen draining from the ear - Wicking
more than 14 days - Quinolone Otic drops (14 days)
• (-) pain - FF: 5 days
4. Ear infection

No Ear Infection
• (-) Pus - No treatment
• (-) pain
5. Malnutrition
Complicated Severe Acute Malnutrition (CSAM)
• Edema of both feet - Keep patient Warm
OR - Antibiotic: Amoxicillin
• Weight for Height or Length (WFH/L) - Refer
-3z score - Sugar water
OR
• MUAC <115 mm
And any of the ff:
1. Medical complication
2. Not able to finish RUTF
3. BF problem
5. Malnutrition
Uncomplicated Severe Acute Malnutrition (USAM)
• Edema of both feet - Counselling the mother
OR - Amoxicillin – 5 days
• Weight for Height or Length (WFH/L) - RUTF 6 months and up
-3z score - FP: 7 days
OR - Assess for possible TB
• MUAC <115 mm - Return
And any of the ff:
1. Medical complication
2. Able to finish RUTF
3. BF problem
5. Malnutrition
Moderate Acute Malnutrition (MAM)
• Weight for Height and Length - FF: 30 days
(WFHL) -3z and -2z score - Assess for TB
OR - FP: 7 days
• MUAC 115 to 125 mm - Counsel and assess the feeding
- Return immediately
5. Malnutrition

No Acute Malnutrition (NAM)

• Weight for Height and Length - FF: 30 days
(WFHL) -2z score - Assess the child’s feeding
OR - FP: 7 days
• MUAC 125 mm and up - Counsel the mother
4. Anemia

Severe Anemia
• Severe palmar pallor - Refer
4. Anemia
Anemia
• Some palmar pallor - FF: 14 days
- Iron – 14 days
- Return immediately
- Mebendazole/Albendazole
4. Anemia

No Anemia
• No Palmar Pallor - Assess & Counsel
- FP: 5 Days
4. HIV
Confirmed HIV Infection
• (+) virological test in child - Cotrimoxazole prophylaxis
OR - Refer for TB and INH therapy
• (+) serological test in a child 18 - Advise for home care
months or older - Assess and counsel for feeding
- FF regularly
- ART treatment
4. HIV
HIV Exposed
• (+) Mother and (-) virological - Cotrimoxazole prophylaxis
test in a BF child/only stopped - Do virological test to confirm
less than 6 weeks - FF regularly
OR - Refer for TB
• (+) Mother while child is not - Advise for home care
yet tested - Assess and counsel for feeding
OR - ARV treatment
• (+) Serological test in <18
months of a child
4. HIV

HIV Infection Unlikely

• (-) HIV test in mother or child - Treat, counsel and follow-up
existing infections
 INFANT TO 2 MONTHS
Sick Young Infant
Bacterial Infection (less than 2m)
Very Severe Disease
• Any GDS - Refer urgently
• Fast breathing - Intramuscular antibiotics
• Chest indrawing - Sugar water
• Fever or low body temperature - Advise to keep infant warm
• Movement only when
stimulated or no movement at
all
Bacterial Infection (less than 2m)
Local Bacterial Infection
• Umbilicus red or draining pus - Oral antibiotic
• Skin pustules - Teach mother to treat local infxn
- Advise mother to give home care
- Follow up in 2 days
Bacterial Infection (less than 2m)
Severe Disease or Local Infection Unlikely
• Not enough signs - Advise the mother to give home
care
Jaundice

Severe Jaundice
• Any jaundice if age less than 24 - Sugar water
hours - Advise to keep patient warm
• Yellow palms and soles at any - Refer urgently
age
Jaundice

Jaundice
• Jaundice appearing after 24 - FF: 1 day
hours of age and - Advise to give home care
• Palms and soles not yellow - Advise to return immediately
- Refer
Jaundice

No Jaundice
• No jaundice - Advise to give home care
Feeding Problem (BF)
Feeding Problem or Low Weight
• Not well attached to breast
• Not sucking effectively or <8
BF in 24 hours
• Receives other foods or drinks
• Low weight for age
• Thrush (ulcers or white patches
in mouth)
- IF not well attached/poor
sucking: teach mother
- IF BF <8x in 24 hours: advise to
BF as often as possible
- IF with other foods: advise to
reduce and increase more BF
- IF not BF at all: refer got
counselling and BM substitute
- IF with thrush, teach how to treat
it at home
Feeding Problem (BF)
Feeding Problem or Low Weight
• Not well attached to breast - Advise to keep pt warm if low
• Not sucking effectively or <8 for weight
BF in 24 hours - Advise mother to give home care
• Receives other foods or drinks - FF: feeding problem or thrush in
• Low weight for age 2 days
• Thrush (ulcers or white patches - FF: Low weight for age in 14
in mouth) days
Feeding Problem (BF)
No Feeding Problem
• Not enough signs and - Advise to give home care
symptoms - Praise the mother for feeding
well
Feeding Problem (Non BF)
Feeding Problem or Low Weight
• Milk incorrect/unhygienically
prepared
• Inappropriate/Insufficient
replacement feeds
• HIV positive mother before 6
months
• Feeding bottle
• Low weight for age
• Thrush
- Counsel about feeding
- Explain the guidelines for
feeding replacement
- Identify concerns of mother and
family
- Teach cup feeding
- Keep patient warm
- Treat thrush at home
- Home care
Feeding Problem (Non BF)
Feeding Problem or Low Weight
• Milk incorrect/unhygienically - FF: 2 days
prepared - FF: 14 days
• Inappropriate/Insufficient
replacement feeds
• HIV positive mother before 6
months
• Feeding bottle
• Low weight for age
• Thrush
Summary of Follow-ups
Jaundice 1 day
Feeding Problem with Thrush; Local 2 days
Bacterial Infection
Pneumonia, Dysentery & Fever 3 days
Feeding Problem (Malnutrition) 7 days
Follow-up for Malnutrition 30 days
Anemia, Feeding Problem/Low 14 days
weight (Infant Less Than 2 Months)
Ear Infection, Some Dehydration, No 5 days
Dehydration, Persistent Diarrhea,
Cough or Colds