Integrated Management of Childhood Illnesses (IMCI)

Definition
  • IMCI is an integrated approach to child health that focuses on the well-being of the whole child.
  • IMCI strategy is the main intervention proposed to achieve a significant reduction in the number of deaths from communicable diseases in children under five
Goal
  • By 2010, to reduce the infant and under five mortality rate at least one third, in pursuit of the goal of reducing it by two thirds by 2015.
Aim
  • To reduce death, illness and disability, and to promote improved growth and development among children under 5 years of age.
  • IMCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilities.
IMCI Objectives
  • To reduce significantly global mortality and morbidity associated with the major causes of disease in children
  • To contribute to the healthy growth & development of children
IMCI Components of Strategy
  • Improving case management skills of health workers
  • § Improving the health systems to deliver IMCI
  • Improving family and community practices

**For many sick children a single diagnosis may not be apparent or appropriate

Presenting complaint:
  • Cough and/or fast breathing
  • Lethargy/Unconsciousness
  • Measles rash
  • “Very sick” young infant
Possible course/ associated condition:
  • Pneumonia, Severe anemia, P. falciparum malaria
  • Cerebral malaria, meningitis, severe dehydration
  • Pneumonia, Diarrhea, Ear infection
  • Pneumonia, Meningitis, Sepsis
Five Disease Focus of IMCI:
  • Acute Respiratory Infection
  • Diarrhea
  • Fever
  • Malaria
  • Measles
  • Dengue Fever
  • Ear Infection
  • Malnutrition
The IMCI Case Management Process
  • Assess and classify
  • Identify appropriate treatment
  • Treat/refer
  • Counsel
  • Follow-up
The Integrated Case Management Process
Check for General Danger Signs:
  • A general danger sign is present if:
    • The child is not able to drink or breastfeed
    • The child vomits everything
    • The child has had convulsions
    • The child is lethargic or unconscious
Assess Main Symptoms
  • Cough/DOB
  • Diarrhea
  • Fever
  • Ear problems
Assess and Classify Cough of Difficulty of Breathing
  • Respiratory infections can occur in any part of the respiratory tract such as the nose, throat, larynx, trachea, air passages or lungs.
Assess and classify PNEUMONIA
  • Cough or difficult breathing
  • An infection of the lungs
  • Both bacteria and viruses can cause pneumonia
  • Children with bacterial pneumonia may die from hypoxia (too little oxygen) or sepsis (generalized infection).

** A child with cough or difficult breathing is assessed for:

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  • How long the child has had cough or difficult breathing
  • Fast breathing
  • Chest indrawing
  • Stridor in a calm child.

Remember:

    • ** If the child is 2 months up to 12 months the child has fast breathing if you count 50 breaths per minute or more
    • ** If the child is 12 months up to 5 years the child has fast breathing if you count 40 breaths per minute or more.
Color Coding
 PINK
(URGENT REFERRAL)
 YELLOW
(Treatment at outpatient health facility)
 GREEN
(Home management)
 OUTPATIENT HEALTH      FACILITY
  • Pre-referral treatments
  • Advise parents
  • Refer child
 OUTPATIENT HEALTH FACILITY
  • Treat local infection
  • Give oral drugs
  • Advise and teach caretaker
  •  Follow-up
 HOME
  • Caretaker is counseled on:
  • Home treatment/s
  • Feeding and fluids
  • When to return immediately
  • Follow-up
 REFERRAL FACILITY
  • Emergency Triage and Treatment ( ETAT)
  • Diagnosis, Treatment
  • Monitoring, follow-up

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

  • Give first dose of an appropriate antibiotic
  • Give Vitamin A
  • Treat the child to prevent low blood sugar
  • Refer urgently to the hospital
  • Give paracetamol for fever > 38.5oC
  •  Any general danger sign or
  • Chest indrawing or
  • Stridor in calm child
PNEUMONIA
  •  Give an appropriate antibiotic for 5 days
  • Soothe the throat and relieve cough with a safe remedy
  • Advise mother when to return immediately
  • Follow up in 2 days
  • Give Paracetamol for fever > 38.5oC
  • Fast breathing
NO PNEUMONIA : COUGH OR COLD
  •  If coughing more than more than 30 days, refer for assessment
  • Soothe the throat and relieve the cough with a safe remedy
  • Advise mother when to return immediately
  • Follow up in 5 days if not improving
  •  No signs of pneumonia or very severe disease
Assess and classify DIARRHEA

 A child with diarrhea is assessed for:

  • How long the child has had diarrhoea
  • Blood in the stool to determine if the child has dysentery
  • Signs of dehydration.
Classify DYSENTERY
  • Child with diarrhea and blood in the stool
 Two of the following signs?

  • Abnormally sleepy or difficult to awaken
  • Sunken eyes
  • Not able to drink or drinking poorly
  • Skin pinch goes back very slowly
SEVERE DEHYDRATION
  • If child has no other severe classification:
    • Give fluid for severe dehydration ( Plan C ) OR
  • If child has another severe classification :
    • Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
    • Advise the mother to continue breastfeeding
  • If child is 2 years or older and there is cholera in your area, give antibiotic for cholera
 Two of the following signs :

  • Restless, irritable
  • Sunken eyes
  • Drinks eagerly, thirsty
  • Skin pinch goes back slowly
SOME DEHYDRATION
  • Give fluid and food for some dehydration ( Plan B )
  • If child also has a severe classification :
    • Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
    • Advise mother when to return immediately
  • Follow up in 5 days if not improving
  •  Not enough signs to classify as some or severe dehydration
NO DEHYDRATION
  • Home Care
  • Give fluid and food to treat diarrhea at home ( Plan A )
  • Advise mother when to return immediately
  • Follow up in 5 days if not improving
  •  Dehydration present
SEVERE PERSISTENT DIARRHEA
  • Treat dehydration before referral unless the child has another severe classification
  • Give Vitamin a
  • Refer to hospital
  •  No dehydration
PERSISTENT DIARRHEA
  • Advise the mother on feeding a child who has persistent diarrhea
  • Give Vitamin A
  • Follow up in 5 days
  •  Blood in the stool
DYSENTERY
  • Treat for 5 days with an oral antibiotic recommended for Shigella in your area
  • Follow up in 2 days
  • Give also referral treatment
Does the child have fever?

    **Decide:

  • Malaria Risk
  • No Malaria Risk
  • Measles
  • Dengue
Malaria Risk
  •  Any general danger sign or
  • Stiff neck
VERY SEVERE FEBRILE DISEASE / MALARIA
  • Give first dose of quinine ( under medical supervision or if a hospital is not accessible within 4hrs )
  • Give first dose of an appropriate antibiotic
  • Treat the child to prevent low blood sugar
  • Give one dose of paracetamol in health center for high fever (38.5oC) or above
  • Send a blood smear with the patient
  • Refer URGENTLY to hospital
  •  Blood smear ( + )

If blood smear not done:

  • NO runny nose, and
  • NO measles, and
  • NO other causes of fever
MALARIA
  • Treat the child with an oral antimalarial
  • Give one dose of paracetamol in health center for high fever (38.5oC) or above
  • Advise mother when to return immediately
  • Follow up in 2 days if fever persists
  • If fever is present everyday for more than 7 days, refer for assessment
  • Blood smear ( – ), or
  • Runny nose, or
  • Measles, or Other causes of fever
FEVER : MALARIA UNLIKELY
  • Give one dose of paracetamol in health center for high fever (38.5oC) or above
  • Advise mother when to return immediately
  • Follow up in 2 days if fever persists
  • If fever is present everyday for more than 7 days, refer for assessment
No Malaria Risk
  • Any general danger sign or
  • Stiff neck
VERY SEVERE FEBRILE DISEASE
  • Give first dose of an appropriate antibiotic
  • Treat the child to prevent low blood sugar
  • Give one dose of paracetamol in health center for high fever (38.5oC) or above
  • Refer URGENTLY to hospital
  • No signs of very severe febrile disease
FEVER : NO MALARIA
  • Give one dose of paracetamol in health center for high fever (38.5oC) or above
  • Advise mother when to return immediately
  • Follow up in 2 days if fever persists
  • If fever is present everyday for more than 7 days, refer for assessment
Measles
  • Clouding of cornea or
  • Deep or extensive mouth ulcers
SEVERE COMPLICATED MEASLES
  • Give Vitamin A
  • Give first dose of an appropriate antibiotic
  • If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment
  • Refer URGENTLY to hospital
  • Pus draining from the eye or
  • Mouth ulcers
MEASLES WITH EYE OR MOUTH COMPLICATIONS
  • Give Vitamin A
  • If pus draining from the eye, apply tetracycline eye ointment
  • If mouth ulcers, teach the mother to treat with gentian violet
  • Measles now or within the last 3 months
MEASLES
  • Give Vitamin A
Dengue Fever
  • Bleeding from nose or gums or
  • Bleeding in stools or vomitus or
  • Black stools or vomitus or
  • Skin petechiae or
  • Cold clammy extremities or
  • Capillary refill more than 3 seconds or
  • Abdominal pain or
  • Vomiting
  • Tourniquet test ( + )
SEVERE DENGUE HEMORRHAGIC FEVER
  • If skin petechiae or Tourniquet test,are the only positive signs give ORS
  • If any other signs are positive, give fluids rapidly as in Plan C
  • Treat the child to prevent low blood sugar
  • DO NOT GIVE ASPIRIN
  • Refer all children Urgently to hospital
  • No signs of severe dengue hemorrhagic fever
FEVER: DENGUE HEMORRHAGIC UNLIKELY
  • DO NOT GIVE ASPIRIN
  • Give one dose of paracetamol in health center for high fever (38.5oC) or above
  • Follow up in 2 days if fever persists or child shows signs of bleeding
  • Advise mother when to return immediately
Does the child have an ear problem?
  • Tender swelling behind the ear
MASTOIDITIS
  • Give first dose of appropriate antibiotic
  • Give paracetamol for pain
  • Refer URGENTLY
  • Pus seen draining from the ear and discharge is reported for less than 14 days or
  • Ear pain
ACUTE EAR INFECTION
  • Give antibiotic for 5 days
  • Give paracetamol for pain
  • Dry the ear by wicking
  • Follow up in 5 days
  •  Pus seen draining from the ear and discharge is reported for less than 14 days
CHRONIC EAR INFECTION
  • Dry the ear by wicking
  • Follow up in 5 days
  •  No ear pain and no pus seen draining from the ear
NO EAR INFECTION
  •  No additional treatment
Check for Malnutrition and Anemia

Give an Appropriate Antibiotic:

A. For Pneumonia, Acute ear infection or Very Severe disease

COTRIMOXAZOLE

BID FOR 5 DAYS

AMOXYCILLIN

BID FOR 5 DAYS

Age or Weight

 

Adult

tablet

 

Syrup

 

Tablet

 

 

Syrup

 

2 months up to 12 months ( 4 – < 9 kg )

1 / 2

5 ml

1 / 2

5 ml

12 months up to 5 years ( 10 – 19kg )

1

7.5 ml

1

10 ml

B. For Dysentery

 

COTRIMOXAZOLE

BID FOR 5 DAYS

AMOXYCILLIN

BID FOR 5 DAYS

 

 

AGE OR WEIGHT

 

TABLET

 

SYRUP

 

SYRUP 250MG/5ML

 

2 – 4 months

( 4  – < 6kg )

 

½

 

5 ml

1.25 ml ( ¼ tsp )

 

4 – 12 months

( 6 – < 10 kg )

½

 

5 ml

2.5 ml ( ½ tsp )

 

1 – 5 years old

( 10 – 19 kg )

1

 

7.5 ml

( 1 tsp )

 

C. For Cholera

TETRACYCLINE

QID FOR 3 DAYS

COTRIMOXAZOLE

BID FOR 3 DAYS

 AGE OR WEIGHT

Capsule 250mg

Tablet

 Syrup

2 – 4 months ( 4  – < 6kg )

¼

1 / 2

5ml

4 – 12 months ( 6 – < 10 kg )

½

 1 / 2

5 ml

1 – 5 years old ( 10 – 19 kg)

1

1

7.5ml

Give an Oral Antimalarial

CHOLOROQUINE

Give for 3 days

Primaquine

Give single dose in health center for P. Falciparum

Primaquine

Give daily for 14 days for P. Vivax

Sulfadoxine + Pyrimethamine

Give single dose

AGE

TABLET ( 150MG )

TABLET

( 15MG)

TABLET

( 15MG)

TABLET

( 15MG)

 

DAY1

DAY2

DAY3

 

 

 

2months –

5months

½

½

½

 

 

¼

5 months –

12 months

½

½

½

 

 

1/2

12months –

3 years old

 

1

1

½

½

¼

¾

3 years old  –

5 years old

1 ½

1 ½

1

3/4

1/2

1

GIVE VITAMIN A

 AGE  VITAMIN A CAPSULES  200,000 IU
 6 months – 12 months  1/2
 12 months – 5 years old  1

GIVE IRON

 AGE or WEIGHT  Iron/Folate Tablet
FeSo4 200mg + 250mcg Folate (60mg elemental iron)
 Iron Syrup
FeSo4 150 mg/5ml
(6mg elemental iron per ml )
 2months-4months
(4 – <6kg )
 2.5 ml
 4months – 12months
(6 – <10kg )
 4 ml
 12months – 3 years        (10 – <14kg)  1/2  5 ml
 3years – 5 years ( 14 –  19kg )  1/2  7.5 ml

GIVE PARACETAMOL FOR HIGH FEVER (38.5oC OR MORE) OR EAR PAIN

 AGE OR WEIGHT  TABLET ( 500MG )  SYRUP ( 120MG / 5ML )
 2 months – 3 years        ( 4 – <14kg )  ¼  5 ml
 3 years up to 5 years     (14 – 19 kg )  1/2  10 ml

GIVE MEBENDAZOLE

  • Give 500mg Mebendazole as a single dose in health center if :
    • hookworm / whipworm are a problem in children in your area, and
    • the child is 2 years of age or older, and
    • the child has not had a dose in the previous 6 months