IMCI – Integrated Management of Childhood Illness

By: Apple G. Alvarez, RN, MN

Started in

• 1992 particularly by the UNICEF, WHO, DOH and AUSAID

• Strategy• Reducing

Childhood Illnesses

• Mortality• Morbidity

Mortality

• Death of large numbers

• Number of deaths in a given place or locality

Morbidity

• Rate of incidence of disease

Integrated Management of Childhood Illness (IMCI)

Birth 1 week 2 months 5 years

Pregnancy

IMCI case management guidelines

Why 1 week to 2 months up to 5 years?

• First week of life• Labor and Delivery

• Special Management

IMCI again...

• CASE MANAGEMENT PROCESS

• First-level facility

Guidelines – How to?

• Care brought to a clinic

• Illness• Scheduled

follow up visit to check the child’s progress.

Guidelines INCLUDES:

1. Instructions (routine assessment)

2. Treatment3. Basic

Activities – Illness Prevention

4. Do not describe management of trauma

• Other acute emergencies due to accidents or injuries

4. If sought an untrained provider

• Too late for assessment

• Death!• Teaching –

IMPORTANT > Case Process

TAKE NOTE:• Understandable

terms • In shaking the child -

- GENTLE

• Second hand watch.• UNDRESS the child

• Longitudinal – Pinching of the abdomen

• 2 months – SPOON

• 6 months – with a cup

• If sunken eyes - - ASK if USUAL

• Malaria Risk Area– Davao Del Norte– Davao Oriental– Sarangani– Sultan Kudarat

• Petechiae – Folds– Thigh

• Use pediatric cuff –tourniquet test

• New EPI Administrative Order– BCG– Hepatitis B– 1st dose– Before Discharge

• Iodine Deficiency = Iodized Salt

• Anemic Pregnancy = Iron Supplement

• Vit. A Deficiency = Micronutrients

• Second Line = Availability of drug

• Oresol• Home made solution

– 1 teaspoon of salt– 4 teaspoons of sugar– 1 liter of water

Fully Immunized – before 12 months of age

• BCG 1• DPT 1• DPT 2• DPT 3• OPV 1• OPV 2• OPV 3• HB 1• HB 2• HB 3• Measles

Problems why IMCI exist?

1. The under five population is the most vulnerable group

2. Child mortality remains UNACCEPTABLY HIGH

3. Many of these deaths had no medical attendance or being seen by first –level health facilities

4. First-level facilities: -

undermanned/underpaid

- HW’s are not appropriately TRAINED

- drug supply inadequate/not properly

managed - inaccessible - poor laboratory

support

5. Family and community profile/ practices

- late “help seeking” behavior

- poor utilization of health facilities

- literacy - traditional

beliefs/traditions - economic - large families - crowded, dense,

polluted environment

IMCI - OBJECTIVES

1. To reduce SIGNIFICANTLY global mortality and morbidity associated with the major causes of disease in children

• 2. To contribute to healthy growth and development of children

A must to take note:

“TRAINING DESIGN to teach integrated management of sick infants and children to first level HW’s in primary care settings that have NO laboratory support and only a limited number of essential drugs.”

“ Action oriented CLASSIFICATIONS ,

rather than EXACT DIAGNOSES, are used.”

“ A careful balance has been struck

between SENSITIVITY and SPECIFICITY

“Using FEW CLINICAL SIGNS as

possible which health workers of diverse background can be trained

to recognize”

“ The IMCI guidelines rely on detection of cases based on SIMPLE CLINICAL SIGNS,

without laboratory tests, and offer EMPIRIC TX “

COLOR CODING

PINK

• Severe• URGENT PRE REFERRAL

• Hospital/Treatment

YELLOW

With Moderate Needs

Management – Rural Health Unit

Specific Medical Treatment

Advice

GREEN

Mild

Home Care

Simple Advice

5 steps in IMCI case management

1. Assess and Classify

2. Identify Treatment3. Treat4. Counsel the

Mother5. Follow Up

ASSESS

Left side column how to take a history and do a physical examination

CLASSIFY

Decision severity of ILLNESS

IDENTIFY TREATMENT

To quickly identify treatment for the classifications

Written on your case recording form.

Case Recording Form

Documentation!At the back of the form

After assessment

IMPORTANT BEFORE ASSESSMENT –

1st

• Know which the child age belongs– 1 week up to 2

months– 2 months up to 5

years

2nd

– Name– Age in

months– Weight in

kilograms– Temperatur

e and etc.

Remember!

• Mothers knows best!

3rd

• Initial• Follow

Up

Initial visit

1st VISIT

Episode of Illness

Follow up visit

Seen a few days ago for the same illness

Condition – improved or still the same

THE CASE PROCESS

I. Assess for the 4 GENERAL DANGER

SIGNS• Not able to

drink• Severe Vomiting • Convulsions • Abnormally

Sleepy

Not able to drink …• If the child is:

–Too weak to drink–Not able to

suck/swallow when offered a drink/breastfeed

»If the nurse is not sure upon assessment – ASK THE MOTHER to offer a child to drink (clean water/breast milk)

»IMPORTANT: Check if the child’s nose is blocked!

» POOR SUCKING

Severe Vomiting …

• EVERTHING!!

Convulsions …

DURING THE ILLNESS

Arms and legs – stiffening!

Jerky Movements

Loss of consciousness – even if eyes are open

SHIVERING !!! – not a convulsion

Abnormally Sleepy …Drowsy

Not interested with surroundings

Stares blankly

No response - - even when TOUCH, SHAKEN or SPOKEN to.

If child is asleep and has COUGH or DIFFICULT

Breathing, it is essential to:– Count the number

of breaths BEFORE waking up the CHILD

– Why? So it is easier to get the accurate breathing rate.

In cases, there are presences of ANY danger signs - - as in

ANY...

Complete Assessment Form

Pre referral treatment immediately!

REFERRAL is not delayed!

II. Assess for COUGH / DIFFICULTY in

BREATHING

1. In breathing• LOOK and LISTEN

to STRIDOR• Harsh noise when

the child BREATHS IN

2. In cough• HOW LONG?• Chronic?• More than 30

days

Rules 1-4

Count BREATHS per minute

CHILD - - quiet and calm

Do not count . . . .!

Ask the mother - -> Lift the child’s shirt

Fast Breathing

If the child is Fast breathing is:

1 months -12 months

50 breaths/minute or more

12 months- 5 years

40 breaths/minute or more

Is there breathing IN or OUT?

NORMAL CHEST INDRAWING

The whole chest wall and abdomen move OUT when the child breaths IN

The LOWER CHEST WALL goes IN when the child BREATHS IN

Best Position to Check

• Lying down

Stridor means..

• Harsh Noise Breathing IN

• Swelling of the:– Larynx– Trachea

–Epiglottis

How to check for STIDOR?

• The nurse must PUT her ear near the child’s MOUTH

• While breathing IN and OUT• Harsh noise while BREATHING OUT –

NOT A STRIDOR!

III. Assess for DIARHEA

IMCI definition : DIARRHEA

3 or more loose or watery stools

in a 24 hour period

Questions to ask..

• How long?• Blood in the STOOL?• Signs of

DEHYDRATION?

If there is DIARRHEA

• Further assessment includes:– Dehydration– Persistent

Diarrhea• 14 days or more

– Dysentery

Dysentery

– Infection of the intestine marked by severe diarrhea , usually of the lower intestinal tract

If suspected DEHYDRATION

Check if there are signs like:

• Abnormally sleepy/difficult to awaken

• Restless and irritable AS IN ALL THE TIME!

• Sunken eyes If the nurse is not sure, please ask the MOTHER if the manifestation is usual to the child’s appearance.

Offer the child fluid - - - with a CUP or a SPOON

Not able to drink Not able to take fluid in mouth and swallow

Drinking poorly If weak and cannot drink without help

Drinking eagerly, thirsty

Reaches out for the water offered

Pinch the skin of the abdomen

Skin goes back VERY SLOWLY

Longer than 2 seconds

Skin goes back SLOWLY

Stays for a BRIEF TIME after release

IV. Assess for FEVER

IMCI definition : FEVER

– History of fever – no present fever but had fever within 72 hours

– Feels HOT

– Axillary temperature

= 37.5’c

Checking on Malaria Risk• Been in places with malaria in

the past 4 weeks– Look/feel for STIFF NECK

• If child bends/moves neck easily as he looks around

• Draw the child’s attention to his TOES

• Gently support BACK and BEND the HEAD forward to his CHIN

• Look for RUNNY NOSE – not HISTORY of runny nose!

• Look for SIGNS Of MEASLES

Signs of Measles• Generalized rash• Any: cough, runny nose,

red eyes• Measles rash -

behind the EARS, NECK, spreads to the face and to the rest of the BODY

• No vesicles or pustules –no itchiness!

And if there was MEASLES now or WITHIN the last 3 months

ASSESS FOR:

1. Mouth ulcers –painful (inside of the mouth, lips or tongue)

2. PUS draining from the eye

3. Clouding of the cornea (hazing of the cornea)

Assess for DENGUE HEMORRHAGIC FEVER

1. Only to those who are 2 months of age or older

2. Look for signs of BLEEDING/SHOCK:

• Bleeding from the nose & gums

• Skin petechiae– Small

hemorrhages in the skin

– Small dark spots/patches in the skin

– Not raised– Not tender– Not lose its color when

the skin is stretched

3. Cold and clammy extremities

– Check for slow capillary refill (longer than 3 seconds)

4. Tourniquet Test!– Done:

» when there are no signs in the ASK/LOOK and FEEL

» Is 6 months» Fever is present more

than 3 days

How is tourniquet test done?• Rumpel-Leede Capillary-

Fragility Test• Based on counting

petechiae in a given area of the arm

• A blood pressure cuff is applied and inflated to a point between the systolic and diastolic blood pressures

• Positive more than 20 petechiae per square inch - - caused by a minor hemorrhage).

• After application of the rubber cuff - sphygmomanometer

• 5 minutes.

IV. Assess for EAR PROBLEM

• Palpate• Look• Smell

Only assessed the following:

1. Ear pain

2. Ear Discharge3. Tender swelling

behind the ear

IF:

Present less than 2 weeks

Acute EAR infection

Present 2 weeks or more

Chronic EAR infection

MASTOIDITIS

ACUTE EAR INFECTION

CHRONIC EAR INFECTION

NO EAR INFECTION

V. Assess for MALNUTRITION & ANEMIA

MARASMUSVisible Severe Wasting

KWASHIORKOREdema of both feet

ANEMIAPalmar Pallor

Weight for ageBasis for Nutrition

Imbalanced

Treating Local Infections @ HOME

Eye Infection – Tetracycline Ointment

• 3 times• Inside - lower lid

Dry the EAR by WICKING

• 3X daily• Roll – tissue paper in a wick• Ear• Remove wick when wet• Repeat until dry

Mouth Ulcers – gentian violent

• Half strength• 0.2 %

Soothe the THROAT – Relieve COUGHSAFE REMEDY

• Breast milk – for exclusively breastfed

• Tamarind• Calamansi• Ginger• Harmful Remedies:

– Codeine Cough Syrups– Oral and Nasal

Decongestants

Prevent low blood sugar

• If the child not able to BREASTFEED

• 30 ml of milk• SUGAR WATER

To make sugar water

• 4 level of teaspoons of SUGAR (20 grams)

• 200 ml clean cup water

• If the child – not able to swallow

• 50 ml – milk / sugar water

• NGT