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:

• 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 (38.5^oC 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

Reference:
Ms Ma. Adelaida Morong, Far Eastern University- Institute of Nursing
In-House Nursing Review