INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS

[IMNCI]

INTRODUCTION-

Common childhood illness like acute respiratory infection, diarrhea, measles, malaria
and malnutrition result in high mortality among children less than 5 year of age. Neonatal mortality
contributes to over 64% of infant death and most of these deaths occur during the first week of life.

Integrated management of neonatal and childhood

illness [IMNCI] strategy ,develop by world health organization in collaboration with UNICEF and many
other agencies in mid 1990, is a curative , preventive and primitives strategy aimed at reducing the
death and frequency and severity of illness and disability and contribute to improve growth and
nutrition of under five children.

The strategy has been expanded in India to include neonatal care at

home as well as in the health facilities and renamed as “INTEGRATED MANAGEMENT OF NEONATAL
AND CHILDHOOD ILLNESS “ [IMNCI].

DEFIONITION-

WHO/ UNICEF have developed a new approach to tackling the major disease of early
childhood called the IMNCI.

AIMS OF IMNCI-

1 Provide quality care of sick children.

2 childhood vaccination should be given to reduce measles.

3 Oral rehydration therapies have contributed to a major reduction in diarrheal death.

4 Provide good treatment of malaria.

5 Improve the breast feeding practice to reduce childhood death.

6 Advice to do laboratory tests and not to the x-ray for neonates.

7Educatae about effectiveness and affordable use of drugs and diagnostic tools.

8 Assess common signs and symptoms and provide sufficient information to guide rational and effective
action.

9 Promotion of growth.
OBJECTIVES OF IMCI-

1 To reduce deaths.

2 To reduce frequency and severity of illness and disability .

3 To improve growth and development . The strategy has been expanded in India to include all neonatal
and renamed it as IMNCI.

The IMNCI clinical guideline target children of less than 5 year old.

The death rate is high in children below 5 year of age . The common cause are ARI, diarrhea, malaria and
measles .

The evidence based syndrome approach can be used to determine:

-Health of the child.

-Severity of the health condition.

-Action to be taken for care of child.

ADDITIONAL IMNCI FUNCTION-

-Active involvement of family members and community in the health care process.

- Adjustment of intervention to the capacity of the health system.

SERVICES PROVIDED UNDER IMNCI-

1 Vaccination services

2 Breast feeding

3 Management of ARI

4 Vitamin A and micro nutrient supplement

5 Prevention of diarrhea

6 Prevention of malnutrition

7 Malaria control program

8 Counselling on various health problem.

COMPONENT OF THE INTEGRATED APPROACH-

The IMNCI strategy is both preventive and curative . The

three main components are:

1 Improvement in the case management skill of health staff.

2 Effective management of neonatal and childhood illness.

3 Improvement in family and community health case practices.

IMNCI BENE FICIARIES-

-Care of newborn and young infant [Infant under 2 month]

- Care of infants [2months to 5year ]

CARE OF NEWBORN AND YOUNG INFANT[INFANT UNDER 2 MONTH]-

1 keeping the child warm.

2 Initiating of breast feeding.

3 Counseling for exclusive breast feeding ,cord , skin and eye care.

4 Recognition of illness in newborn and management or referral.

5 Immunization.

6 Home visit in the postnatal period.

CARE OF INFANT [2 MONTH TO 5 YEAR]-

1 Management of diarrhea, ARI, malaria, measles, acute ear infection, malnutrition and anemia.

2 Recognition of illness and risk.

3 Prevention and management of iron and vitamin A deficiency.

4 Counseling on feeding for all children below 2 year.

5 Counseling on feeding for malnourished.

6 Immunizations.

PRINNCIPLES OF INTEGRATED CARE –

Depending on a child’s age, various clinical signs and symptoms

differ in their degree of reliability and diagnostic value and importance IMNCI clinical guidelines focus on
neonates, infants as well as children up to 5 year of age . However , in view of similarities in the
spectrum of illness , clinical sign and management protocol , the treatment guideline have been brodly
divided into 2:-

-Young infant up to 2 month of age.

- Children 2 month up to 5 year of age.

2 month of age – All sick infant should be assessed for bacterial infection , jaundice and diarrhea.

2 month to 5 year-

-Assess for danger sign.

- Routine assess for major symptoms like cough or difficulty in breathing , diarrhea , fever, and ear
problems.

So, IMNCI guidelines is based on the following principles:

1 All sick children under 5 year of age must be examined for condition which indicate , immediately
referral or hospitalization .

2 Children must be routinely assessed for major system nutritional and immunization status , feeding
problem.

3 Only a limited number of carefully selected clinical signs are used based on evidence of their sensitivity
and specificity to detect disease.

4 Based on the presence of selected clinical signs the child is placed in a ‘classification ‘ . Classification
are not specific diagnosis but categories that are used to determine the treatment .

5 Classification are colour coded and suggest refer( pink) , treatment in health facility (yellow) or
management at home (green).

6 IMNCI guidelines address most common , but not all pediatric problems.
7 A limited number of essential drugs are used.

8 Care taker are actively involved in the treatment of children.

9 Counseling of caretaker about home are including feeding, fluids and when to return to health facility .

IMNCI CASE MANAGEMENT PROCESS-

Steps of case management process are as follows :

1 Assess the young infant / child

2 Classify the illness .

3 Identify Treatment

4 Treat the young/ Infant child.

5 Counsel the mother

6 Provide follow up care.

Step I – III Assess, Classify and Identify treatment

A- Assess : <2 Months of age

All sick infants should be assessed for bacterial infection, jaundice and diarrhea.

2 months to 5 years –

 Assess for danger signs.

 Routinely assess for major symptoms like cough or difficult breathing,diarrhea,fever and ear
problems.
They also be assessed for nutritional and immunization status,feeding problems and other
potential problem.

Clinical assessment of the child-

The important signs of serious bacterial infection –

- convulsion

- Fast breathing [60 breath / min ]

- chest in drawing
 - nasal flaring

- grunting

- bulging fontanel

- pus draining from the ear

- temperature

- lethargy or unconsciousness

- less than normal movement

SIGNS OF SEVERE DEHYDRTION-

 Lethargic or unconscious
 Looks restless /irritable
 Sunken eyes
 Elasticity of skin

SIGN OF SOME DEHYDRATION-

 Restless , irritable
 Sunken eyes
 Skin pinch goes back slowly

SIGN OF FEEDING PROBLEM –

- Not well attached to breast or not sucking effectively.

- Less than 8 breastfeed in 24 hours.
- Receiving other foods or drinks.
- Thrush (ulcer or white patches in mouth)
- Breast or nipple problem

ASSESSMENT OF SICK PROBLEM –

1 History taking and informing about the child problem to health care provider.

2 Checking several danger sign (vomiting, inability to drink and lethargy )

3 Checking main symptoms

4 Checking formal nutrition

5 Checking for anemia

6 Assessment of child feeding

7 Checking immunization status

8 Assessing other problems

CLASIFY- Whenever you use a classification table, start with pink rows. If the young child/ infant does
not have the severe classification, look at yellow rows. If the child does not have any sign in the pink or
yellow row select the classification from green rows.

- Pink – suggest hospital referral or admission

- Yellow – indicates initiation of specific treatment
- Green- calls for home management

CLASSIFICATION OF POSSIBLE BACTERIAL INFECTION –

There are two possible classification for

bacterial infection:

1 POSSIBLE SERIOUS BACTERIAL INFECTION-

 Convulsion
 Fast breathing (60 breath / min)
 Severe chest in drawing
 Nasal flaring
 Grunting
 Bulging fontanel’s
 Axillaries temperature 37.5 c (or above or feel hot to touch ) or temperature less
than 35.5 c
 Lethargy or unconsciousness
 Less than normal movement
 2 LOCAL BACTERIAL INFECTION-

 Umbilicus red or draining pus

 Pus discharge from ear

CLASSIFICATION OF JAUNDICE –
There are two possible classification –

1 SEVERE JAUNDICE-

 Yellow palm and soles

 Appear in less than 24 hour of age
 Persist for more than 14 days

2 JAUNDICE -

 Palms and soles are not yellow

 Age 1-13 days

CLASSIFICATION OF DEHYDRATION-

Dehydration is classified into:

1 SEVERE DEHYDRATION-

 Lethargic or unconscious
 Sunken eye
 Skin pinch goes back very slowly

In severe dehydration , the fluid loss is greater than 10% of the body weight .

(treatment suggest by WHO)

2 SOME DEHYDRATION –

 Restlessness , irritable
 Sunken eyes
 Skin pinch goes back slowly

In some dehydration , the fluid loss is 5-10% of body weight

( Treatment B)
3 NO DEHYDRATION-

The patient with diarrhea do not have enough sign to classify as dehydration .

Fluid loss less than 5% of body weight .

( treatment A )

CLASSIFICATION OF FEEDING PROBLEM AND MALNUTRITION-

All sick infant may be classified into 3

1 NOT ABLE TO FEED-

 Possible serious bacterial infection

 Severe malnutrition
 Not able to feed or no attachment at all or not or very low weight for age

2 FEEDING PROBLEM –

 Not well attached to breast

 Not sucking effectively
 Less than 8 breast feed in 24 hours
 Low weight for age
 Receiving other food or drinks
 Breast or nipple problem

NO FEEDING PROBLEM-

 Not low weight for age and other sign of inadequate feeding
 Infant are breastfeed exclusively at least 8 times in 2 hours.

CLASSIFICATION OF FEVER –

Very severe febrile disease can be considered. If the child is having –

 Any danger sign

 Stiff neck
 Bulging fontanel

Malaria is considered , if child is having fever of temperature at or above 37.5 c

Malaria is unlikely if child is having

 Running nose
 Measles
 Other cause of fever

CLASSIFICATION OF MALNUTRITION –

-SEVERE MALNUTRITION-
 Edemas of both feet
 Weight for age is low

-NOT VERY LOW WEIGHT –

 Not very low weight for age

 No sign of severe malnutrition

CLASSIFICATION OF ANEMIA –

1 severe anemia ; severe palmer pallor

2 Anemia, some palmer pallor

3 No anemia, no palmer pallor

CLASSIFICATION OF MEASLES-

1 SEVERE COMPLICATED MEASLES-

 Any danger sign

 Clouding of cornea
 Deep or extensive mouth ulcers

2 Measles with eye or mouth complication-

 Pus drainage from eye

 Mouth ulcer

CLASSIFICATION OF EAR PROBLEM-

1 ACUTE EAR INFECTION – ( The duration is less than 14 days)

 Ear pain
  Pus is draining from the ear
2 CHRONIC EAR INFECTION-
Pus is seen draining from the ear for 14 days or more.

3 MASTOIDITIS – Tender swelling behind the ear

4 NO EAR INFECTION- No ear pain and no ear discharge seen

IDENTIFY TREATMENT – All the treatment required are listed in the “identify treatment ‘’ column if a sick
young infant /child has more than one classification, treatment required for all the classification must be
identified.

STEP IV- Treat the young infant / child based on the classification and treatment suggested under
‘identify treatment’ an infant is managed with pre referral treatment for severe classification, outpatient
treatment and management at home.

1 Referral- Al l infant and children with a severe classification (pink) are reoffered to a hospital as soon
as assessment is completed and necessary pre-referral treatment is administered .

Successful referral of severely ill children to the hospital

depend on effective counseling of the care taker if she/ he should be given a short , clear referral note ,
and should get information on what to do during referral transport , particularly . if the hospital is
distant . also remember the following point :

 If the infant or child is convulsing – give diazepam 0.2 mg /kg i/v or rectally
 If convulsion continuous for 10 min – give second dose of diazepam
 Use Phenobarbital 20 mg /kg i/m to control convulsion in infant less than 2 week of age
 Prevent low blood sugar by giving breast milk or sugar water
 Warm the young infant by skin to skin contact , specially on the way to hospital referral
 If child had only severe dehydration and no other severe classification ,iv infusion to be started
in the outpatient clinic
 A single dose of cefteriazone (100mg/kg) or cefotamine (50 mg/kg)can also be given a pre-
referral antibiotic therapy.

2 OUT PATIENT-

Treatment – The treatment associated with each non referral classification (yellow and
green) is clearly spelled out in the IMNCI guidelines chart booklet. Treatment uses minimum affordable
essential drugs.
ORAL DRUG – Always start with a first line drug .These are usually less expensive , more readily available
and easier to administer. Give a second line drug only if a first line drug is not available, or if the child’s
illness does not respond to the first line drug. The health care need to teach the mother or care taker
how to give oral drug at home.

ORL ANTIBIOTIC - The IMNCI chart shows how many and how many times each day to give the
antibiotics. Only cholera cases receive antibiotic for three days. Determine the correct dose of antibiotic
based on the child’s weight. Always check if the same antibiotic can be used for treatment of different
classification a child may have for example3, the same antibiotic could be used to treat both pneumonia
and acute ear infection.

ORAL ANTIMALARIAL- Chloroquine and sulfadoxine prime thiamine are the first – line and second line
drugs recommended by the national anti- malarial program in India. In high, malaria risk areas,
chloroquine is given for three days with a single dose of primaquin (to children older than one year)on
the first day . This is the complete treatment of p. falciparum malaria. If the blood smear is found to be
p. vivax positive, the child should be given primaquin for 5 days .

PARACETAMOL- If the child has a high fever, give one dose of paracetamol in the clinic . If child has ear
pain give the mother enough paracetamol for one day, that is four doses . Tell her to give one dose
every six hours or until the ear pain is gone.

IRON- A child with anemia needs iron. Give syrup to child under 12 month of age. If child is older than 12
month, give iron tablet give one dose daily for 14 days . Ask her to return for more iron in 14 days. Also
tell the mother that iron may make the child’s stool black.

VITAMIN A- Vitamin A is given to child with severe malnutrition. Vitamin A is available in syrup forum.
Use the child age to determine the dose give two doses. Every dose of vitamin A should be recorded
because of danger of an overdose.

SAFE REMEDY FOR COUGH AND COLD- There is no evidence that commercial cough and cold remedies
are any more effective than simple home remedies in relieving a cough or smoothing a sore throat.
Suppression of a cough is not desirable because cough is a physiological refer to eliminate lower
respiratory tract secretion. Breast milk is a good soothing remedy.

Step 5

Counsel the mother- A child who is seen in the clinic needs to continue treatment ,feeding and fluids at
home. The child’s mother or caretaker also needs to recognize when the child is not improving or is
becoming sicker. The success of home treatment depends upon how to give treatment, understand its
importance and knows when to return to a health care provider.

EFFECTIVE COMMUNICAION- It is critical to communicate effectively with the infant’s mother or care
taker. Proper communication helps to reassure the mother or care taker that the infant will receive
appropriate care . Encourage the mother or caretaker to ask question and then answer all question.
  Advice to continue feeding and increase fluids during illness.
 Teach how to give oral drug or to treat local infection.
 Counsel to solve feeding problem .
 Advice when to return.

A IMMEDIATELY- Advice to return immediately if the child has any of these ysigns:
1 Any sick child -Not able to drink
-Become sicker
- Develop breathing

2 If child has no pneumonia - fast breathing

cough or cold , Also return if - difficult breathing

- Blood in stool
- drinking poorly

B FOLLOW UP- If the child has

Pneumonia , dysentery, malaria, if fever persist

Diarrhea, if not improving feeding problem 2 days

Any other illness , if not improving 5 days

Anemia, very low birth weight for age 14 days

STEP VI-

FOLLOW UP CARE- At a follow up visit see if the child is improving on the drug or other treatment that
was prescribed. Some children may not respond to a particular antibiotic or ant malarial , may need to
try a second.

SELECT AGE – APPROPRIATETREATMENT CHART

Sickyoung
Sick younginfant
infantage
ageupuptoto2 2month
month Sick
Sick child
child age
age 2 month
2 month upup
toto 5 year
5 year

Check for possible –Bacterial infection Danger

Dangersign
sign:Convulsion
:
Check for possible :
 Convulsion
 Bacterial sign
 Lethargy/ unconscious
 Jaundice
 Inablity to drink
 Vomiting
 Assess the symptoms for : Cough/ difficult breathing
Assess the symptoms for
Diarrhea  Diarrhea
 Fever
 Ear problem
–

Assess for:
Check for : Assess the symptoms for:

 Feeding problem and malnutrition  Cough / difficult breathing

 Immunization  Diarrhea
 Fever
 Ear problem

Check for other problem

Classify illness and identify treatment use

Color coded treatment chart