IMCIIs simply the umbrella program through which all community health intervention

can be delivered to children under 5 years of age

Brief History of IMCI• 1992 1ST developed by: UNICEF

(United Nations Children’s Emergency fund) and WHO

• AIM: To prevent or early detection and TX of the leading cause of childhood death; reduce childhood mortality and morbidity by improving family and community practices for home management of illness, and improving case management of skills of health workers in the bigger health system

• 1995 – IMCI introduced in the Phil. As a strategy to reduce child death and promote growth and development

• 19970 - implementation started with a memorandum agreement bet. ADPCN & APSOM – Ass. Of Phil,. School of Midwifery in April 2002

GOALS

• To reduce the Infant and under-five mortality rate by at least one third in 2010

• To reduce the –Infant and under-5 mortality rate by at least two thirds in 2015

How does IMCI accomplish This Goals ?• Adopting an integrated approach to child health and development in

the national health policy;• Adapting standard IMCI clinical guidelines to the country’s needs,

available drugs, policies and to the local foods and language used by the population;

• Upgrading care in local clinics by training health workers in the new methods to examine and treat children, and to effectively counsel parents

• Making upgraded care possible by ensuring that enough of the right low-cost medicines and simple equipment are available;

• Strengthening care in hospitals for those children too sick to be treated in outpatient clinic;

• Developing support mechanism within communities for preventing disease, for helping families to care for sick children, and for getting children to clinic or hospital when needed

Why is IMCI better than Single-condition Approaches?

• Children brought for medical treatment in the health facility are often suffering from more than one condition, thus making a single diagnosis impossible. The IMCI takes into account the combined Tx of the major childhood illnesses. Emphasizing prevention of disease through Immunization and improved nutrition

inimalinimal or non-existent Diagnostic toolsor non-existent Diagnostic tools

onditions onditions Overlap (other prob.)Overlap (other prob.)

elies on history and signs & symptomselies on history and signs & symptoms

quipment & Drugs are scarcequipment & Drugs are scarce

bility of Health workers to practice bility of Health workers to practice complicated clinical procedures are fewcomplicated clinical procedures are few

COMPONENTS OF IMCI• upgrading the case management and

counseling skills of health care providers• strengthening the health care system

for effective management of childhood illnesses

• improving the family and community health practices related to childhood and nutrition

Benefits of IMCI and Who Will benefit From it?

C – cost-effective of intervention-gainful and profitable interventions for investors

H – High Impact on health status of childrenL- low-cost and promotes cost-savingof resourcesD – demands of children answered-IMCI focuses on the

major causes of illness and death of children: ARI, malnutrition, measles, malaria, dengue

R – responsive to major child health problemsE – equity of access to health care improvedN – not only curative, but preventive as well

Other Benefits:• Promotes accurate identification of childhood

illness in outpatient settings• Ensure appropriate combined treatment for

all major illness• Strengthens the counseling of caretakers and

provision of preventive services• Speed up referral of severely ill children• Promotion of appropriate care-seeking

behavior in the home setting, improved nutrition and preventive care, and the correct implementation of prescribed care

Focus of IMCI in the Philippines – PD2M3

P - PNEUMONIAD - DENGUED - DIARRHEAM - MALARIAM - MEASLESM - MALNUTRITION

AGE CATEGORIES OF IMCI

• CHILDREN AGE 2 MONTHS UP TO 5 YEARS• YOUNG INFANTS AGED 1 WEEK UP TO

MONTHS

• ASSESS the child by checking first the danger signs (or possible

bacterial infection in a young infant)– asking questions about common conditions– examining the child– checking nutrition and immunization status– Includes checking the child for other problems

CLASSIFY a child’s illness using color-coded triangle system

Simple advice on home management (GREEN)

Specific medical treatment and advice (YELLOW)

Urgent pre-referral treatment

and referral (PINK)

Elements of

IMCI

IDENTIFY specific treatments for the childIf requires urgent referral, give

essential treatment before the patient is transferred

If the child requires treatment at home, develop an integrated plan for the child and give the 1st dose of drugs in the clinic

If a child should be immunized , give immunization

IDENTIFY specific treatments for the childIf requires urgent referral, give

essential treatment before the patient is transferred

If the child requires treatment at home, develop an integrated plan for the child and give the 1st dose of drugs in the clinic

If a child should be immunized , give immunization

Elements of

IMCI

Provide practical TREATMENT instructionsTeaching the caretaker on oral drug

administrationHow to feed and give oral fluids during illnessHow to treat local infections at homeAsk the caretaker to return for follow up on a

specific dateTeach the caretaker on how to recognize signs

that indicate that the child should be return immediately to the health facility

Provide practical TREATMENT instructionsTeaching the caretaker on oral drug

administrationHow to feed and give oral fluids during illnessHow to treat local infections at homeAsk the caretaker to return for follow up on a

specific dateTeach the caretaker on how to recognize signs

that indicate that the child should be return immediately to the health facility

Elements of IMCIElements of IMCI• Assess feeding, including breastfeeding

practices. COUNSEL to solve any feeding problem found. Then counsel the mother about her own health

• When a child is brought back to the clinic as requested, GIVE FOLLOW UP CARE and if necessary, reassess the child for new problems

Check for General Danger Signs

• Inability to drink or breastfeed• Convulsions• Lethargy or

unconsciousness–Abnormally sleepy or difficult to awaken

• Vomiting everything taken.

• ASK: is the child able to drink or breastfeed?– A child has this sign if he/she is too weak to

drink and is not able to suck or swallow when offered a drink

– If you are not sure about the mother’s answer, ask her to offer the child a drink. Look to see the child’s response

– Breastfeeding children may have difficulty sucking when their nose is blocked , clear it first

• ASK: Does the child vomit everything?–A child who is

not able to hold on anything down at all has the sign “vomits everything”

A child with ANY of the Danger Signs has a serious problem and needs URGENT referral to the hospital

ASK: Has the child had convulsions?Use the term for convulsions like “fits”, “spasm”, or “jerky

movements” which the mother understands

LOOK: See if the child is abnormally sleepy or difficult to awakenAn abnormally sleepy child is drowsy and does not show interest

in what is happening around him/herHe does not look at his mother or watch your face when you talkHe may stare blankly and does not notice what is going on

around himHe does not respond when she is touched, shaken or spoken to

ASK: Has the child had convulsions?Use the term for convulsions like “fits”, “spasm”, or “jerky

movements” which the mother understands

LOOK: See if the child is abnormally sleepy or difficult to awakenAn abnormally sleepy child is drowsy and does not show interest

in what is happening around him/herHe does not look at his mother or watch your face when you talkHe may stare blankly and does not notice what is going on

around himHe does not respond when she is touched, shaken or spoken to

I. Cough or Difficulty in breathing

I. Cough or Difficulty in breathing

Assess for general danger signs. This child may have pneumonia or another severe respiratory infection. After checking for danger signs, it is essential to ask the child’s caretaker about this main symptom.

• Clinical AssessmentThree key clinical signs are used to assess a sick child with cough or difficult breathing:

1. Respiratory rate, which distinguishes children who have pneumonia from those who do not;

2. Lower chest wall indrawing, which indicates severe pneumonia; and

3. Stridor, which indicates those with severe pneumonia who require hospital admission.

Assess for general danger signs. This child may have pneumonia or another severe respiratory infection. After checking for danger signs, it is essential to ask the child’s caretaker about this main symptom.

• Clinical AssessmentThree key clinical signs are used to assess a sick child with cough or difficult breathing:

1. Respiratory rate, which distinguishes children who have pneumonia from those who do not;

2. Lower chest wall indrawing, which indicates severe pneumonia; and

3. Stridor, which indicates those with severe pneumonia who require hospital admission.

Cough or Difficulty in breathingStridor is a harsh noise made when the child inhales (breathes in). Children who have stridor when calm have a substantial risk of obstruction and should be referred.

Wheezing is heard when the child exhales (breathes out). This is not stridor. A wheezing sound is most often associated with asthma.In some cases, especially when a child has wheezing when exhaling, the final decision on presence or absence of fast breathing can be made after a test with a rapid acting bronchodilator (if available).

Cough or Difficulty in breathingLower chest wall indrawing: inward movement of the bony structure of the chest wall with inspiration, is a useful indicator of severe pneumonia.

It is more specific than “intercostal indrawing,” which concerns the soft tissue between the ribs without involvement of the bony structure of the chest wall.

Chest indrawing should only be considered present if it is consistently present in a calm child. Agitation, a blocked nose or breastfeeding can all cause temporary chest indrawing.

Cough or Difficulty in breathing

If The Child is :

2 weeks to 2 months

2 to 12 months

12 months t o 5 years old

Fast Breathing is :

60 or more per minute

50 or more per minute

40 or more per minute

THE INTEGRATED CASE MANAGEMENT PROCESS

OUT PATIENT HEALTH FACILITY

Check for DANGER SIGNConvulsions

Abnormality sleepy or difficult to awakenUnable to drink / breastfeed

Vomits everything

Asses MAIN SYMPTOMSCough / difficulty breathing ,chestindrawing

DiarrheaFever

Ear Problem

Asses NUTRITION,ANEMIA, IMMUNIZATION, and VITAMIN A SUPPLEMENTATION STATUS and POTENTIAL FEEDING PROBLEM

Check for OTHER PROBLEMS

CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONAccording to color-coded treatment

Urgent Referral

OUTPATIENT HEALTH FACILITY

Pre-referral treatmentAdvise parents

Refer child

REFERRAL FACILITY

Emergency Triage and Treatment (ETAT)DiagnosisTreatment

Monitoring and follow-up

Home Management

HOME

Caretaker counseled on:Home treatmentsFeeding and Fluids

When to return immediatelyFollow-up

Treatment in outpatient facility

OUTPATIENT HEALTH FACILITYTreat local infection

Give oral drugsAdvise and teach caretaker

Follow-up

COUGH OR DIFFICULTY IN BREATHING

DIARRHEA

Plan A : Treating Diarrhea at Home

1. Determine The amount of ORS to give during the 1st 4 hours

2. Show the mother how to give ORS SOLUTIONREASSESS and CLASSIFY

THE CHILD FOR DEHYDRATION

After 4 Hours

AGE WEIGHT AMOUNT (mL)

Below 4 months < 6 kg 200-400

4 to 12 months 6 to < 10 kg 400-700

12 months to 2 years 10 to < 12 kg 700-900

2 to 5 years old 12 to < 19 kg 900-1400

Use the child’s age only when You do not know his or her weight. The approximate amount of ORS required (in mL) can also be calculated by

multiplying the child’s weight (in kg) by 75

Plan C : Treat Severe Dehydration Quickly

Can you give IV fluid immediately?Can you give IV fluid immediately?

Is IV treatment available nearby (within 30

minutes)?

Is IV treatment available nearby (within 30

minutes)?

Are you trained to use NGT for

rehydration?

Can the child drinkCan the child drink

Refer the child urgently to a hospital for IV / NGT treatment

Refer the child urgently to a hospital for IV / NGT treatment

Yes

Yes

Give the child IV fluid in your Health Center

Refer the child URGENTLY to a hospital

Give ORS by NGT or by mouth

Persistent Diarrhea

Deciding if there is Malaria Risk1. Category ProvincesA-Provinces with no significant improvement in

malaria situation in the last ten years or the situation worsened in the last five years, the average cases is more than 1,000 in the last ten years. (Agusan del sur, Cagayan Davao,Palawan,Quezon,Tawi-tawi etc)

B-Provinces where the situation has imporved in the last five years or the average number of cases is 100- 1,000 cases. (Abra,Bataan,Ilocos Norte, Pangasinan,Romblon etc.)

C. Provinces with a significant reduction in cases in the last five years ( Albay, Batanes, Batangas ,Marinduque etc)

D. Provinces that are malaria-free, although some are potentially malarious due to vectors ( Aklan, Bohol, Capiz, Cebu etc)

• Travelling at least 4 weeks• 2. Season --------------Rainy Season

Blood smear (+)

If the blood smear test is not done :NO runny nose, andNO measlesNO other causes fever

MALARIA

Any general danger signStiff neck

VERY SEVERE FEBRILE DISEASE / MALARIA

No sign of very severe febrile disease

FEVER : NO MALARIA

MALARIA RISK

( Including travel to a malaria-risk area)

MALARIA RISK

( Including travel to a malaria-risk area)

NO MALARIA

RISK

NO MALARIA

RISK

CLASSIFY FEVERCLASSIFY FEVER

Any general danger signStiff neck

VERY SEVERE FEBRILE DISEASE / MALARIA

Blood smear (-), orRunny nose, orMeasles, orOther causes of fever

FEVER : MALARIA UNLIKELY

MALARIA RISK

Oral AntimalarialFirst Line : CHLOROQUINE and PRIMAQUINESecond Line : SULFADOXINE and PYRIMETHAMINE

If CHLOROQUINE and PRIMAQUINE Explain the mother that she should watch he child carefully

for 30 minutes after giving him or her a dose of chloroquine. If the child vomits within 30 minute, she should repeat the dose and return to the health center for additional tablets

Explain that itching is a possible side effect of the drug, and that it is not dangerous

IF SULFADOXINE + PYRIMETHAMINE Give a single dose in the health center

MEASLES

EAR PROBLEM

Asses Malnutrition :1.Determine weight for

age.2.Look for edema of

both feet.3.Look for visible severe

wasting.4.For children aged 6

months or more, determine if MUAC* is less than 115 mm.

ANEMIA

Give Iron: Give 1 dose for 14 days daily AGE OR WEIGHT

IRON/FOLATE TABLET

Ferrous sulfate 200 mg + 250 mcg Folate

(60 mg Elemental iron)

IRON SYRUPFerrous Sulfate 150

mg per 5 ml(6 mg elemental

iron per ml)

IRON DROPSFerrous Sulfate

25 mg(25 mg elemental

iron per ml)

3 months up to 4 months (4 - <6 kg)

2.5 ml (1/2 Tsp) 0.6 ml

4 months up to 12 months (6 - <10 kg)

4 ml (3/4 tsp) 1.0 ml

12 months up to 3 years (10 - <14 kg)

½ tablet 5 ml (1 tsp) 1.5 ml

3 years up to 5 years (14 - <19 kg)

1 tablet 10 ml (2 tsp) 2.0 ml

Albendazole

Albendazole treats hookworm and whipworm infection.

These infections contribute to anemia because of iron loss through intestinal bleeding

Check the young Infant’s Immunization and Vitamin A Status

AGE VACCINE VITAMIN AImmu- Birth BCG, Hep B-1 Give 200,000 IU nization to the mother within 4 weeks after delivery

Schedule 6 weeks DPT-1,OPV1 HEP-B2 Give all missed doses on this visit Include sick infants unless being referred Advise the caretaker when to return for the dose

An Appropriate Oral Antibiotics FOR FIRST LINE SECOND LINE

Pneumonia Cotrimoxazole Amoxycillin

Acute Ear Infection

Cotrimoxazole Amoxycillin

Very Severe Disease

Cotrimoxazole Amoxycillin

Dysentery Cifrofloxacin Nalidixic Acid

Cholera Tetracycline Cotrimoxazole

INTEGRATED CASE MANAGEMENT PROCESS FOR INFANT (2 WEEKS-2 MONTHS

Bacterial InfectionThe Infant’s Feeding

THE INFANT’S FEEDING

Jaundice

DEHYDRATION

Dehydration

FEEDING PROBLEM

CARE FOR DEVELOPMENTI. What is care for development?II. Assesing the child’s care for development.III. Identify Problems in Care for development. Lack

of time; communication gap; play; environmentIV. Counsel the mother about care for

development.V. Counsel the mothe about her own health.

Some Common Feeding Problems1. Difficulty in breastfeeding2. Child less than 4 months taking other

milk/food3. Use of breast milk substitute, e.g., cow’s

milk, evaporated milk4. Use of feeding bottles5. Lack of active feeding

6. Not feeding well during illness7. Complementary food not enough in

quantity/quality/variety8. Child 6 months or older, but not yet given

complementary foods9. Infant not exclusively breastfed10. Improper handling and use of breast milk

substitute

When to Return-Follow up VisitIF THE CHILD HAS: RETURN FOR

FOLLOW-UP

PNEUMONIAWHEEZEDYSENTERYMALARIA, if fever persistsFEVER:MALARIA UNLIKELY,if fever persists FEVER NO MALARIA, if fever persistsMEASLES WITH EYE OR MOUTH COMPLICATIONSDENGUE HEMORRHAGIC FEVER UNLIKELY,if fever persists

2 DAYS

KERPERSISTENT DIARRHEAACUTE EAR INFECTIONCHRONIC EAR INFECTIONFEEDING PROBLEMSANY OTHER ILLNESS, if not improving

5 DAYS

ANEMIA

14 DAYS

VERY LOW WEIGHT FOR AGE 30 DAYS

WHEN TO RETURN IMMEDIATELYADVISE THE MOTHER TO RETURN IMMEDIATELY IF THE CHILD HAS ANY OF

THESE SIGNS

ANY SICK CHILDNOT ABLE TO DRINK OR BREASTFEDBECOMES SICKERDEVELOPS A FEVER

IF THE CHILD HAS NO PNEUMONIA: COLD,OR COUGH, also return if:

FAST BREATHINGDIFFICULT BREATHING

IF THE CHILD HAS DIARRHEA, also return if:

BLOOD IN THE STOOLDRINKING POORLY

IF CHILD HAS FEVER :DENGUE HEMORRHAGIC FEVER UNLIKELY,also return if:

ANY SIGN OF BLEEDINGPERSISTENT ABDOMINAL PAINPERSISTENT VOMITINGSKIN PETECHIAESKIN RASH

Case study No. 3Baby a is a 3 years old