Community Health Nursing

Integrated Management for

Childhood Illnesses (IMCI)
Prepared by:
RANIEL MARQUEZ, MAN, RN
 INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
(IMCI)
 WHAT IS IMCI?
 a strategy for reducing mortality and morbidity
associated with major causes of childhood illness
 A joint WHO/UNICEF initiative since 1992

 OBJECTIVES
 To reduce SIGNIFICANTLY global mortality and
morbidity assoc. with the major causes of disease in
children
 To contribute to healthy growth and development of
children
CASE MANAGEMENT PROCESS:
 Case Management Process can be used by doctors,
nurses, and other health professionals who see sick
infants and children aged one week to five years. The
Case Management Process is relevant process for a
first-level facility that have NO laboratory support and
only a limited number of essential drugs such as a
clinic, health center, and/or the outpatient department
of a hospital.
Steps in Case Management
Process:
1. Health workers ASSESS the sick child

 - Assessing the child means taking down his or her history and doing a
physical examination on him or her.
 IDENTIFY any danger sign present:
 Assess the child by checking first for danger signs (i.e, convulsions,
lethargy/ unconsciousness, inability to drink/breastfeed, and
vomiting) or possible bacterial infection in an infant.
 ASK about the four(4) main symptoms cough, diarrhea, fever, and ear
problem
 Ask the mother questions about common conditions related to the
child’s condition
 REVIEW nutrition, Vit A ,immunization
2. Health worker CLASSIFIES child’s illness

- Classifying the illness means making a decision as regards the severity

of illness
 - Classify a child’s illness using a color-coded triage system:
PINK = urgent pre-referral and referral
Urgent pre-referral treatment:
First level/outpatient health facility
 Give pre-referral treatment
 Advise the parents
 Refer the child
Referral:
 Emergency triage and treatment (ETAT)
 Diagnosis
 Treatment
 Monitoring
 Follow-up
YELLOW = specific medical tx, and
advice
 Treat local infection
 Give oral drugs
 Advise and teach the caregiver
GREEN = simple advice on home care
 teaching themother or other care giver how to give oral
drugs and treat the local infection at home.
 Counselling the mother or other caregiver about food
(feeding problems), fluids when to return to the health
facility, and her own health.
 3. Health worker IDENTIFY specific treatments for
the child.
- If the child requires urgent referral, give essential treatment before
the patient is transferred.
If a child needs treatment at home, develop an integrated treatment
plan for the child and give the first dose of the drugs in the clinic.
if a child should be immunized, give him or her immunization.

4. Health workers TREATS the child.

 - Treating the child means giving treatment in the health center. It
includes teaching caregivers how to give fluids during illness, and how
to recognize signs indicating that the child should return immediately
to the health facility.
 5. Counsel the mother
 - Councel the mother includes assessing how the
child is to be fed, and telling her about the foods and
fluids to be given to the child, and when to bring the
child back to the health center, then counsel the
mother about her own health.
 6. Give follow-up care
- when the child is brought back to the clinic, as required, give follow-
up care and, if necessary , reassess the child for new problem.
- The case management process for sick children aged 2 months to 5
years is presented in three charts entitled:
Assess and classify the sick child
Treat the child
Counsel the mother
Case management can only be effective to the extent that parents
promptly bring their sick children to a trained health worker for her. If
the parents wait to bring the child to a clinic until the child is
extremely sick, or take the child to an untrained provider, the child is
most likely to die from illness. Therefore, teaching parents when to
seek care for a sick chold is an important part of the case management
process.
Target Clients
 ASSESS AND CLASSIFY THE SICK CHILD AGED 2 MONTHS
UP TO 5 YEARS
 ASSESS AND CLASSIFY THE SICK CHILD AGED 1 WEEK UP
TO 2 MONTHS
At the start of a sick child
(2 months to 5 years) consultation

 Determine if this is an initial or follow-up visit for

this problem.
 Ask the mother what the child’s problems are.
 IMCI Case Management

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
 Stridor must be calm.
✓ 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
Calamansi, ginger, tamarind
❑ 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
 PNEUMONIA
 1st Line Antibiotic Amoxicillin 25mg/kg 2x daily x 3 days
 2nd Line Antibiotic Cotrimoxazole 2 x daily for 3 days

BEFORE: 1st line Cotimoxazole 2 x 5 days

2nd Line Amoxicillin 3 x 5 days

SIGN & TREATMENT for pneumonia & no pneumonia

-If with wheeze, give a trial of rapid-acting inhaled bronchodilator ( up
to 3 cycles) before they are considered as pneumonia & prescribed
antibiotic
-If wheezing ( even if it disappeared after rapid acting bronchodilator)
give inhaled bronchodilator for 5 days
-Use 0.5 ml Salbutamol diluted in 2.0 ml of sterile water per dose
nebulization
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
IV. Category: Severe dehydration
Plan C- Treatment of Severe dehydration –
characterized by refusal to take oral drinks
>Assessment:
Condition – unconscious, lethargic
Fontanel – very sunken
Tears – absent
Mouth / tongue / lips – very dry
Skin turgor – skin returns very slowly
(pinch skin in abdominal region)
>Treatment:
1.give I.V. fluids
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 < 4 mos 4-12 mos

Amount 200-400 400-700
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 yrs 2-5 yrs

Amount 700-900 900-1400
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.
 b
III. Category: Some dehydration
Plan B – treatment of dehydration – mild / moderate
>Assessment:
condition – irritable / restless
fontanel – sunken
eyeball / tears – sunken/absence
mouth / tongue / lips – dry, eagerness to drink
skin turgor – skin returns slowly (abdomen)
>Treatment:
Oresol - < 4 mos:200-400 ml
5 mos-11 mos: 400-600 ml
12 mos-23 mos: 600-800 ml
2-4 y/o: 800-1200 ml
5-14 y/o:1200-2200 ml
15 y/o and above: 2200-4000 ml
*give the above amount of oresol for 1st 4 hours
*always give the maximum range of dose
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.
 b
II. Category: Diarrhea with No dehydration
Plan A: Prevention of Dehydration
> Assessment:
Condition - Normal , well, alert
Fontanel - normal
Eyeball/tears – normal
Mouth/tongue and lips – moist (wet)
Skin turgor test (forearm) – skin returns quickly
>Treatment:
3 F’s: 1. increase fluid – tea, fruit juices from non-fibrous
fruits, buko, am, oresol/LBM: (everytime stool passes
out)
< 2 yrs old 50-100 ml
2-10 yrs old 100-200 ml
10 yrs old and above- as much as tolerated
2. increase feeding – BRAT; DAT – decrease fat
3. fast referral
** thirst : drinks normally
 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
 DYSENTERY :
Ciprofloxacin 15 mg/ KBW 2x a day for 3 days
BEFORE: Nalidixic Acid
 ORESOL: CDD Program Policies
Diarrhea- 2 concepts: 1. frequency- 3 times
or more/day
2. consistency- watery
- Classification:1. mild- 5-10 unformed
stools/24 hours
2. moderate- 10-15
3. > 15 with associated
S & Sxs.
**Don’t give anti diarrheals ex. loperamide and
attapulgite nor antibiotics. Give antibiotic to
specific diarrhea
Types/Categories of Diarrhea:
I. Specific Diarrhea: ex. 1. amoebiasis- EA histolytica-
Protozoa- give metronidazole
2. Cholera- 3x or more; rice watery
stool - EA vibrio cholerae- bacterial-
` give tetracycline
* 1 Pack oresol is to be dissolved in 1 litter of drinking water
Contents in 1 liter solution:
NaCl- 3.5 gms. - retention of H2O
NaHCO3- 2.5 gms. - buffer system
KCl- 1.5 gms.- contraction of smooth muscle
Glucose- 20 gms primary: for assimilation /
absorption of sodium
-Secondary: provides heat and energy
* Home made ORESOL: b
>Volume; H2O- 1000 ml
Sugar- 8 tsp.
Salt- 1 tsp.
>Smaller volume;
1 glass H2O- 250 ml
2 tsp. sugar
¼ tsp salt or a pinch of salt
Fruits for Diarrhea:
A - Apple
- Has pectin & tannin; try to eat skin
- Pectin has an absorbent property
B- Banana
- Has K+ (ideally the skin is the best however one can
eat the flesh. It also has K+.
K- Kaimito
- Eat the flesh in cases of constipation
- In diarrheal cases, eat extracts, milky substances
(dagta) found on the inside of the skin.
D- Duhat
- Eat the skin (Balat): wash first the fruit then sprinkle
with rock salt then shake. One will notice extracts
starts to come out of the fruit (as a result of vigorous
shaking with rock salt).
Fruits to avoid during Diarrhea: Papaya flesh, Pineapple
flesh, Mango, Guyabano, & Kaimito flesh.
BRAT Diet: Banana, Rice, Apple, Tea (tea has
pectin & tannin), toasted bread or toasted rice
beads.
****toasted bread or toasted rice beads has
activated charcoal w/c acts as absorbent.
Direction: in a cup of warm water, add 1 Tbsp.
of toasted rice or bread and allow to stand for
20-30 mins. The blackish discoloration
obtained is Pectin.
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
 Blood transfusion
w/in past
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
 MALARIA
- Give Artemether-Lumefantrine
 P. Falciparum Treatment : Day 1 - 3 Artemeter –Lumefantrine (
Coartem)
 P. Vivax Treatment: Day 1 - 3 Chloroquine x 3 days
Day 4 – 17 Primaquine
 Mixed P. Falciparum & P. Vivax : Day 1 - 3 Artemeter + Lumefantrine
Day 4 - 17 Primaquine
 Drug Resistant Malaria : Refer w/ Bld Smear of Day 7, 14, 21 & 28
: Give Quinine sulfate 300 or 500 mg/tab AND
Clindamycin 10 mg/kg 2x a day for 3DAYS
 Pre-referral treatment: Give Artesumate suppository for
uncomplicated P. falciparum in infants or young children who cannot
swallow
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
• Calamine lotion for itchiness
• Follow up in 2 days
Measles now or w/in last 3 mos
No other signs

Measles

• Vitamin A
• Calamine lotion for itchiness
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
 CHRONIC EAR INFECTION : Aside from wiking
give Otical Quinolone ear drops x 2 wks

 ACUTE EAR INFECTION : Oral Amoxicillin

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
PALMAR PALLOR
BIPEDAL EDEMA
SEVERE MALNUTRITION
 : MUAC ( MID-UPPER ARM CIRCUMFERENCE) is included in assessment
 : If referral is not possible, give Modified Milk
INFANT FEEDING ( 6 months and below)
 If age 4 months old AND not gaining adequate weight , ADD complementary
food ( give 1 – 2 tbsp 1 – 2 times per day after breastfeeding)
INFANT FEEDING (6 months up to 23 mons).
 If breastfeeding, give complimentary food 3x per day AND 1 – 2 nutritious
snacks
 If NOT breastfeeding, give complimentary food 5 x / day WITH 1 or 2 cups of
milk
 Give small chewable items to eat w/ fingers. Let the child feed by himself,
provide help
 HIV & INFANT FEEDING – if HIV is a public health problem, women should
receive HIV testing & counseling
 If HIV-infected & replacement feeding is possible, avoid breastfeeding
If HIV-infected & replacement is NOT possible, breastfeed on the 1st month
only
POSSIBLE SERIOUS BACTERIAL INFECTION
NOW “VERY SEVERE DISEASE
RANIEL MARQUEZ, RN, MAN
AGAIN
ASSESS AND CLASSIFY THE SICK CHILD
AGED 1 WEEK UP TO 2 MONTHS

MANAGEMENT OF SICK YOUNG

INFANT
 Disease Focus of IMCI
Updated
• Young Infant Age
• 1. at birth up to 2 months old
• 2. any of the following signs and symptoms

• Very Severe Disease

• Convulsions
• Unable to feed or not feeding well
• Abnormally sleepy or no movement at all
• Fever and low body temperature
• Fast breathing
• Chest Indrawing (severe)
•
 Disease Focus of IMCI
• Very Severe Disease (PINK)
• Local Bacterial Infection (YELLOW)
• Severe Disease or Local Bacterial Infection
unlikely (GREEN)
 INCLUSION OF JAUNDICE DURING
ASSESSMENT
ASSESSMENT CLASSIFIC TREATMENT
ATION
Jaundice appearing severe keep the infant warm
less than 24 hours or jaundice treat to prevent low blood sugar
yellow palms at any PINK refer urgently to hospital
age
jaundice appearing jaundice advise mother to give home care
after 24 hours YELLOW Breastfeed frequently:
1. as often and as long as the infant wants
2. day and night
3. during sickness of the health
no jaundice no jaundice advise mother to give home care:
GREEN breastfeed frequently
 Disease Focus of IMCI
• Bacterial Infection
• Diarrhea: dehydration or dysentery
• Feeding Problem or Low Weight
I.A. If with Possible Bacterial Infection
1. Convulsions
2. Child must be calm: Fast Breathing (RR): if ≥ 60 bpm
Severe chest indrawing
Nasal Flaring
Listen for Grunting
3. Look and Feel for bulging fontanelle
4. Look for pus draining from the ear.
5. Assess the umbilicus: redness and pus
6. Take BTemp
7. Assess skin for pustules
8. Assess the child: Abnormally sleepy or difficult to
awaken/ Infant’s movement less than normal
 B. If with diarrhea:
Assess for the ff:
1. General Condition:
– Abnormally sleepy or difficulty to waken,
– restless and irritable,
– sunken eyes,
– pinch skin of the abdomen: very slow (>2 secs) or
slow
2. Duration of diarrhea: >14 days: severe
3. Blood in the stool
 C. If with feeding problems or low
weight
1. Assess for: Any difficulty feeding
– Is breastfeeding less than 8 times in 24 hrs
– Is taking any other foods or drinks, or
– Is low weight for age,
– Has no indications to refer urgently to hospital
2. Assess Infant’s breastfeeding:
– Attachment
– Sucking
3. Look for ulcers or white patches in the mouth
(thrush)
ORAL TRUSH
FOLLOW-UP VISIT TABLE IN THE
COUNSEL THE MOTHER CHART