health programs

1. Integrated Management of
Neonatal and Childhood
Illness
(IMNCI)

2. The age group that bears the highest burden of
deaths from common childhood diseases is
below 5 years of age i.e., UNDER 5 CHILDREN.
Of which
• Birth – 2 months – neonates(up to 7 days
early neonate)
• Up to 1 year - infants

3. CAUSES OF DEATH AMONG CHILDREN UNDER 5 YEARS
55% 45%

4. The most common causes of infant and
child mortality in developing countries
are:
– Acute respiratory infections (17%)
– Diarrhoea (13%)
– Malaria
– Measles and
– Malnutrition (43%).

5.  Overlapping signs and symptoms
 !? Single diagnosis
 Tx of presenting symptoms and also underlying disorders.
 Hence Tx is complicated by a need to combine therapy for
several conditions
 Need for Integrated approach
 Studies reveal that many cases are poorly assessed,
treated and advised.
 Limited lab resources, Radiological procedures, drugs,
equipment at FRU’s.
 Providing quality care has become a serious challenge.

6. Responding to this challenge, WHO, in
collaboration with UNICEF and other
agencies, developed a strategy known
as the Integrated Management of
Childhood Illness (IMCI).

7. INTEGRATION
 For achieving better clinical outcomes, there is a need
to integrate independent services and administrative
processes
 Integration has different meaning at different levels
• At the level of patient – case mangement
• At the level of delivery of health services -
multiple interventions through one channel e.g.vit A &
Measels vaccine
• At system level - bringing together management and
support of diff sub programmes and ensuring the
benefit of one on the other.
IMCI- Only child health strategy that aims at
integration at all these levels simultaneously

8. This strategy has been adapted for India as
Integrated Management of Neonatal and
Childhood Illness (IMNCI).
• Neonatal mortality -45% of infant deaths and most of
these deaths occur during first week of life (first week of
life was not included in IMCI).
• Any health program that aims at reducing IMR needs to
address mortality in the first two months of life,
particularly in the first week of life.
IMNCI is the central pillar of child health
interventions under RCH Phase II strategy.

9. The major highlights of the Indian adaptation are:
a) Inclusion of 0 – 7 days age in the program;
b) Training of the health personnel begins with sick infants up to
2 months (in IMCI, this is done AFTER the training for 2month
– 5 yr, sick children) ;
c) Proportion of training time devoted to sick young infant
(0d – 2months age) and sick child (2months – 5 yr. of age) is
almost equal;
d) Is skill based;
e) Incorporates the national guidelines on
• malaria,
• anaemia,
• vitamin A supplementation and
• immunization schedule.

10. WHAT ARE THE OBJECTIVES?
 Reduce the mortality rate;
 Reduce the frequency and severity of the
illness and disability;
 To contribute to improved growth and
development.

11. What are the Main components of IMCI?
• Improvements in case management skills
of health staff by providing guide lines
and promote their use;
• Improvements in health systems required
for effective management of illness;
• Improvements in family and community
practices.

12. Basis of IMNCI Guidelines
• The IMNCI clinical guidelines target children less than 5 years -
the age group that bears the highest burden of deaths from
common childhood diseases.
• The approach to case management is:
– evidence-based and
– syndromic
• In situations where laboratory support and clinical resources are
limited, the Evidence based Syndromic approach is a more
realistic and cost-effective way to manage patients.
• Careful and systematic assessment of common symptoms and well-
selected clinical signs provides sufficient information to guide
rational and effective actions.

13. • Assessing child’s nutrition, immunisation, feeding
• Counselling and Teaching the parents about the
care at home
• Advising them when to return
• Also recommends to check the parent’s
understanding of advice given and showing the
first dose of treatment.

14. So the guideline help to determine the:
– Health problems the child may have;
– Severity of the child’s condition;
– Actions that can be taken to care for the
child (e.g. refer the child immediately, manage
with available resources, or manage at home)

15. What are the principles of IMNCI clinical guidelines?
• Examining all sick children and young infants
• Assess for main symptoms
• Routine assessment ( nutrition, immunisation, HIV, other problems).
• Limited no. of clinical signs to detect disease through classification
• Classification of illness based on colour coded triage
a) PINK – urgent hospital referral or admission
b) YELLOW – initiation of specific out patient Tx.
c) GREEN – supportive home care.
• Management procedures with limited no. of essential drugs
accordingly.
• Encourages active participation of care givers in Tx
• Counselling of care givers about home care (feeding, when to return
to clinic immediately).
• Follow up care.

17. Main symptoms include:
In sick children
• Cough /difficulty in
breathing
• Diarrhoea
• Fever
• Ear infections
• Acute malnutrition
• Anaemia
• Immunisation; vit-A,
iron-folic acid
supplements.
In sick infants
• Local bacterial
infections
• Diarrhoea
• Jaundice
• Feeding problems /
low weight

18. For e.g. In a case of diarrhoea;
• ASK if the infant / child have diarrhoea?
• If Yes, LOOK and FEEL the signs
• Then CLASSIFY it.

19. • Movement only when stimulated or no movement
at all
• Lethargic or unconscious
• Shrunken eyes
• Not able to drink or poorly drunk
• Skin pinch goes back very slowly
SEVERE
DEHYDRATION
• Restless and irritable
• Shrunken eyes
• Drinks eagerly, thirsty
• Skin pinch goes back slowly
SOME
DEHYDRATION
• Not enough signs to classify as above two
NO
DEHYDRATION
CLASSIFICATION

20. • If child/infant have no other severe classifications then
PLAN C
• If present, refer urgently to hospital with frequent sips of
ORS on the way, continue breast feeding
• If >/= 2 yrs, suspect for cholera, Tx with antibiotic against
it.
SEVERE
DEHYDRATION
• If child/infant have no other severe classifications
then PLAN B
• If present, refer urgently to hospital with
frequent sips of ORS on the way, continue breast
feeding
• Advice when to return immediately
• Follow up follow up in 2 days if not improving
SOME
DEHYDRATION
• Give fluids, Zn supplements and food to treat
diarrhea at home PLAN A
• Advice when to return immediately
• Follow up follow up in 2 days if not improving
NO DEHYDRATION
IDENTIFY TREATMENT

21. TREAT QUICKLY WITH I.V. / NG
• Start i.v fluids immediately (100ml/kg RL Sol
or NS) .
If not available with in 30 min
• Start rehydration orally with naso-gastric
tube intubation.
If not trained for NG tube intubation or
the child is unable to drink
• Refer urgently to hosp for i.v /NG treatment
• Reassess the child every 2 hrs.
• If the child is able to drink give ORS
• Reassess infant after 6hr and child after
3hrs and classify again, choose appropriate
plan A/B/C.
PLAN C (Severe dehydration)
TREAT WITH ORS
• In the clinic ORS is
given for 4 hrs
• Show mother how to
give ORS sol.
• After 4 hrs reassess,
classify, plan
treatment according
to degree of
dehydration plan
A/B/C
• If mother must leave
before completing
treatment
- Explain 4 hr Tx regimen
- Explain 4 rules of home
Tx
PLAN B(Some
dehydration)
TREAT AT HOME
• Counsel the
mother for 4
RULES
• Give extra fluid
(ORS)
• Give ZINC(age
2months -5yrs.)
• Continue
feeding
(exclusive
breast feed if
< 6 months.)
• When to return
PLAN C(No
dehydration)

22. • IMNCI guides MOST, but not all, of the major reasons
of a sick child
? Chronic problems
? Less common illnesses
? Trauma
? Emergencies due to accidents or injuries need
special care
• AIDS (diarrhoea and RTI)- referred to hospital for
special care
• Timely way of approach to trained health worker is
needed for effective case management
Training families when to seek medical care is
important part of case management.

23. In addition to these guidelines meant for peripheral health
workers, Guidelines for training at other levels have also been
developed:
Pre- service IMNCI
• It is being included in the curriculum of medical
colleges of the country.
• This will help in providing the much needed trained
IMNCI manpower in the public and private sector.

24. Facility based IMNCI (F–IMNCI)
• The F-IMNCI training would provide the optimum skills needed
by the Medical officers and Staff Nurses at the First Referral
Units(FRU).
• Thereby helps to address the acute shortage of Paediatricians
at facilities.
• It focusses on providing appropriate inpatient management of
the major causes of neonatal and childhood mortality such as
asphyxia, sepsis, low birth weight, pneumonia, diarrhoea,
malaria, meningitis and severe malnutrition in children at the
FRU’s.

25. THANK YOU