IMCIIntegrated Management

of Childhood Illness(an approach to strengthen the provision of

comprehensive and essential health package to children)

ELEANOR JANE O. DU, RN, RM

General Objective:

• At the of the four hours of Lecture-Discussion the participants will acquire the general knowledge, skills and attitude needed for the application of IMCI strategy in the care of sick children.

Specific Objectives:

1. Trace the history of IMCI in the Philippines.2. Discuss the rationale for an Evidence-based Syndromic

approach to case management of sick children3. Appreciate the Integrated case management process

which includes:a. Assessment of the sick child or infantb. Classify the illnessc. Identify the specific treatmentd. Treat the childe. Counsel the caretakerf. Give follow-up care

IMCI as a strategy● Integrates management of most common

childhood problems● Includes preventive interventions● Adjust curative interventions to the capacity

and functions of the health system● Involves the family members and the

community in the health care process

Rationale for IMCI teaching

● Children accounts 30-70% of all patients in out-patients clinics

● Students have rare opportunities to develop essential out-patient skills

● IMCI guidelines define the most essential knowledge and skills needed to effectively manage sick children.

Indicators of Child Health● Infant and Childhood Mortality● Quality of Care

Improvement in Child Health are not necessarily dependent on the use of sophisticated and expensive technologies but rather on effective strategies that are based on holistic approach.

Why IMCI?● Diagnostic tools are minimal or non-existent● Drugs and Equipments are scarce● Overlap of conditions● Health Workers have few opportunities to

practice complicated clinical procedures● Relies on History and signs and symptoms

Rationale for an evidenced-based Syndromic approach to case

management

● A more integrated approach to managing sick children is needed to achieve better outcomes

● Child Health programs need to move beyond addressing single disease to addressing the overall health and well-being of the child

Objective of the Strategy:

● to reduce death and the frequency and severity of illness and disability

● to contribute to the improved growth and development

This program target children less than 5 years old because this age group bears the highest burden of deaths from common childhood diseases.

Careful and systemic assessment of common symptoms and well-selected specific clinical signs provides sufficient information to guide rational and effective action.

Components of integrated approach:

● Improvement in the case management skills of health staff through the provision of locally adapted guidelines on IMCI and activities to promote their use

● Improvement in the overall health system required for effective management of childhood illness

● Improvement in family and community health care practices.

Principles of Integrated Care:

● All sick children must be examined for “General Danger Signs” which indicate the need for immediate referral or admission to hospital

● All sick children must be routinely assessed for major symptoms● For children age 2 months up to 5 years● Cough● Diarrhea● Fever● Ear Problem● For young infants age 1 week up to 2 months● Bacterial infection● DiarrheaThey must be routinely assessed for nutritional status, feeding problems and other potential problems.

● Only a limited number of carefully-selected clinical signs are used based on evidence of the sensitivity and specificity to detect disease.

● A combination of individual signs leads to a child’s classification rather than a diagnosis.

● The IMCI guidelines address most, but not all the major reasons a sick child is brought to a clinic.

● IMCI management procedures uses a limited number of essential drug and encourage active participation of caretakers in the treatment of children.

● An essential component of the IMCI guidelines is counseling of caretakers about home management including counseling about feeding, fluids and when to return to a healthy facility.

Outpatient management of children age 2 months up to 5 years

● Assessment of sick children includes:● history taking and communicating with the caretaker about the child’s problem● Checking for general danger signs● Checking main symptoms● Checking nutritional status● Assessing the child’s feeding ● Checking immunization status● Assessing other problems

History taking and communicating with the caretaker

Steps to good communication:● listen carefully to what the caretaker

says● Use words the caretaker understand● Give the caretaker time to answer

questions● Ask additional questions when the

caretaker is not sure about the answer

Checking for General danger signs:

The following danger signs should be routinely checked in all children:

● The child has had convulsion● The child is conscious or lethargic● The child is unable to drink or

breastfeed● The child vomits everything

• If the child has one or more of these signs, he/she must be considered seriously ill and will almost always need referral

• In order to start treatment for severe illnesses without delay, the child should be quickly assessed for the most important causes of serious illness and death (ARI, diarrhea, fever, nutritional status)

Checking main symptomsThe Generic IMCI clinical guidelines suggest the

4 main symptoms● Cough or difficulty in breathing● Diarrhea● Fever● Ear problem

Assessing Immunization Status

Illness is not a contraindication to immunization; sick children may be even more in need of protection provided by immunization than well children. A vaccine’s ability to protect is not diminished in sick children.

Four Common situations that are contraindications to immunization of sick

children

● Children who are being referred urgently to the hospital should not be immunized

● Live vaccines (BCG, measles, polio, yellow fever) should not be given to children with immunodeficiency disease or to children who are receiving immunosuppressive agents or radiation.

● DPT2, DPT3 should not be given to children who have had convulsion or shock within 3 days of a previous dose of DPT

● DPT should not be given to children with recurrent convulsion or other active neurological disease of the CNS

Assessing other problemsAddress the child’s other complaints and asks questions about the caretaker’s heath.

Treatment procedure for sick children IMCI classifications are not necessarily specific diagnosis, but they indicate what action needs to be taken.

In IMCI guidelines, all classifications are color coded

● PINK calls for hospital referral or admission

● YELLOW for initiation of treatment

● GREEN means that the child can be sent home with careful advice on when to return.

IMCI case management in Outpatient Health Facility, First level Referral Facility & Home for sick child 2 months-5 year

The Integrated Case Management Process

Outpatient Health Facility

Check for Danger SignsConclusionLethargy/UnconsciousnessInability to drink/BreastfeedVomiting

Assess Main SymptomsCough/Difficult BreathingDiarrheaFeverEar Problems

Assess Nutrition & Immunization Status and Potential Feeding

Problems

Check other Problems

Classify Conditions & Identify treatment action (accdg. to the color coded treatment chart)

URGENT REFERRALTreatment at Outpatient

Health FacilityHome Management

Outpatient Health Facility

Pre-ReferralAdvice ParentsRefer Child

Referral Facility Emergency

Triage Treatment Monitoring &

Follow up

Outpatient Health Facility

Treatment of Local Infection

Give Oral DrugsAdvice & Teach

CaretakerFollow-up

Caretaker is counseled on:

Home TreatmentFeeding & FluidWhen to Return

immediatelyWhen to Return

for follow-up

Outpatient Management of Young Infants age 1 week up to 2 months

Assessment of sick young infants ● Checking for possible bacterial infection● Checking for feeding problems or low

weight● Checking the young infant’s

immunization status● Assessing other problems

Clinical assessment determining weight for age:

● same as that of older children● It includes the following:

● Breastfeeding frequency and night feeds

● Types of complementary foods or fluids, frequency of feeding is active

● Feeding pattern during present illness

Assessing other problems:

● Assess other problems mentioned by the mother or observed during the examination

Treatment procedure for sick infants

Referral of young infant’s age one week up to 2 monthsThe first step is to give urgent pre-referral treatment(s)

which would possibly be● First dose of intramuscular or oral antibiotic● Keep the infant warm on the way to the hospital● Prevention of hypoglycemia with breast milk or sugar water● Frequent sips of ORS on the way to the hospital

Treatment in outpatient clinics

● Oral drugsFirst dose must be given in the clinic. In addition the mother or caretaker should be taught how to give an oral antibiotic at home.

● Treatment of Local infection:There are 3 types of local infections in a sick young infant that caretaker can treat at home

● Umbilicus that is red● Ear that is draining pus

● Skin pustule or thrush

Malarial Risk Areas in the Philippines

•Palawan•Davao Oriental•Davao del Norte•Compostela Valley•Tawi-Tawi•Sulu•Agusan del Sur•Mindoro Occidental•Kalinga•Apayao•Agusan del Norte

•Isabela•Cagayan•Quezon•Ifugao•Zamboanga del Sur•Davao del Sur•Bukidnon•Misamis Oriental•Quirino•Mt. Province•Basilan