INTEGRATED

MANAGEMENT OF
CHILDHOOD
ILLNESS
JAIDEE R. ROJAS, RN
TOPRANK REVIEW ACADEMY
IMCI
• Developed by the World Health Organization (WHO) and United Nations Children’s Fund
(UNICEF).

• Based on the combined delivery of essential interventions at community, health facility

and health systems levels.

• In the Philippines, IMCI was started on a pilot basis in 1996, thereafter more health
workers and hospital staff were capacitated to implement the strategy at the frontline
level.
Objectives of IMCI
• Reduce death and frequency and severity of illness

and disability, and

• Contribute to improved growth and development

Components of IMCI
• Improving case management skills of health

workers

• Improving over-all health systems

• Improving family and community health practices

Rationale for an integrated approach
• Majority of these deaths are caused by 5
preventable and treatable conditions namely: pneumonia,
diarrhea, malaria, measles and malnutrition.

• Most children have more than one illness at one time. This
overlap means that a single diagnosis may not be possible or
appropriate.
Who are the children covered by the IMCI protocol?

• Sick children birth up to 2 months (Sick Young Infant)

• Sick children 2 months up to 5 years old (Sick child)

Strategies/Principles of IMCI
ü All sick children aged 2 months up to 5 years are examined for GENERAL
DANGER signs
ü All Sick Young Infants Birth up to 2 months are examined for VERY SEVERE
DISEASE AND LOCAL BACTERIAL INFECTION. These signs indicate immediate
referral or admission to hospital
ü The children and infants are then assessed for main symptoms.
ü For sick children, the main symptoms include: cough or difficulty
breathing, diarrhea, fever and ear infection.
ü For sick young infants, local bacterial infection, diarrhea and jaundice.
ü All sick children are routinely assessed for nutritional, immunization and
deworming status and for other problems
Strategies/Principles of IMCI
ü Only a limited number of clinical signs are used
ü A combination of individual signs leads to
a child’s classification within one or more
symptom groups rather than a diagnosis.
ü Counseling of caretakers on home care, correct
feeding and giving of fluids, and when to return to
clinic is an essential component of IMCI
BASIS FOR CLASSIFYING THE CHILD’S ILLNESS
• PINK- Urgent hospital referral or admission

• YELLOW- Outpatient Treatment

• GREEN – Supportive home care

Steps of the IMCI Case Management Process
1. Assess the child or infant

2. Classify the illness

3. Identify specific treatments for the child

4. Treat the child

5. Counsel the mother

6. Give follow up care

Steps of the IMCI Case Management Process
1. Assess the child or infant
• History taking and physical examination

• Nutrition and immunization status

• General danger signs

Steps of the IMCI Case Management Process

2. Classify the illness

• Using a color-coded triage system. Since many children

have more than one condition.

Steps of the IMCI Case Management Process
3. Identify specific treatments for
the child
• If a child requires urgent referral, give essential treatment
before the patient is transferred.
• If a child needs treatment at home, develop an integrated
treatment plan for the child and give the first dose of the
drugs in the clinic.
• If a child should be immunized, give him or her
immunization.
Steps of the IMCI Case Management Process

4. Treat the child

• It includes teaching caregivers how to give fluids during
illness and how to recognize signs indicating that the
child should return immediately in the health care
facility.
Steps of the IMCI Case Management Process

5. Counsel the mother

• Foods and fluids to be given to the child
• When to return back to health center
Steps of the IMCI Case Management Process
6. Give follow up care
• When a child is brought back to the clinic, as requested,
give follow-up care and, if necessary, reassess the child
for new problems.
Steps of the IMCI Case Management Process
1. Assess the child or infant

2. Classify the illness

3. Identify specific treatments for the child

4. Treat the child

5. Counsel the mother

6. Give follow up care

GENERAL DANGER SIGNS
ü Vomiting

ü Unable to eat or drink

ü Lethargy

ü Convulsions

!! SEVERE CLASSIFICATION !!
COUGH OR DIFFICULT BREATHING

<2 months= 60 breaths/min

2-12 months= 50 breaths/min
12 months- 5 years = 40 breaths/min
COUGH OR DIFFICULT BREATHING

ANY GENERAL DANGER SIGNS

COUGH OR DIFFICULT BREATHING

STRIDOR IN A CALM CHILD

COUGH OR DIFFICULT BREATHING

RR OF CHILD 12 MONTHS TO 5 YEARS

COUGH OR DIFFICULT BREATHING

YELLOW CLASSIFICATION
COUGH OR DIFFICULT BREATHING

GREEN CLASSIFICATION
COUGH OR DIFFICULT BREATHING

ANTIBIOTIC OF CHOICE FOR PNEUMONIA

COUGH OR DIFFICULT BREATHING

ANTIBIOTIC OF CHOICE FOR SEVERE

PNEUMONIA
COUGH OR DIFFICULT BREATHING

FAST BREATHING
COUGH OR DIFFICULT BREATHING

REFER URGENTLY TO THE HOSPITAL

Classify Diarrhea for Dehydration
Diarrhea for Dehydration

SOME DEHYDRATION
Diarrhea for Dehydration

NO DEHYDRATION
Diarrhea for Dehydration

UNCONSCIOUS
Diarrhea for Dehydration

PLAN C
Diarrhea for Dehydration

DRINKS EAGERLY
Diarrhea for Dehydration

SUNKEN EYES
Diarrhea for Dehydration

SKIN PINCH GOES

BACK SLOWLY
Diarrhea for Dehydration

SKIN PINCH GOES

BACK… VERY … SLOWLY.
Diarrhea for Dehydration

SKIN PINCH GOES

BACK… VERY … SLOWLY.
Diarrhea for Dehydration

PLAN A
Diarrhea for Dehydration

NOT ENOUGH SIGNS TO CLASSIFY

AS SOME OR SEVERE
DEHYDRATION
Diarrhea for Dehydration

PINK CLASSIFICATION
Diarrhea for Dehydration

RESTLESS OR IRRITABLE
Diarrhea for Dehydration

REFER URGENTLY TO THE HOSPITAL

If Diarrhea 14 days or more…
If Diarrhea 14 days or more…

WHAT COLOR IF THERE’S BLOOD IN

THE STOOL?
If Diarrhea 14 days or more…

BLOOD IN THE STOOL?

If Diarrhea 14 days or more…

FOLLOW UP IN FIVE DAYS

If Diarrhea 14 days or more…

FOLLOW UP IN THREE DAYS

If Diarrhea 14 days or more…

FOLLOW UP IN THREE DAYS

If Diarrhea 14 days or more…

SEVERE PERSISTENT DIARRHEA

If Diarrhea 14 days or more…

PERSISTENT DIARRHEA
If Diarrhea 14 days or more…

ANTIBIOTIC OF CHOICE FOR

DYSENTERY
If Diarrhea 14 days or more…

HOW MANY DAYS TO GIVE

CIPROFLOXACIN
If Diarrhea 14 days or more…

REFER URGENTLY TO THE

HOSPITAL
Classify Fever: High or Low Malaria Risk
Classify Fever: High or Low Malaria Risk

ANY GENERAL DANGER SIGNS

Classify Fever: High or Low Malaria Risk

MALARIA TEST POSITIVE

Classify Fever: High or Low Malaria Risk

MALARIA TEST NEGATIVE

Classify Fever: High or Low Malaria Risk

FEVER: NO MALARIA
Classify Fever: High or Low Malaria Risk

ANTIBIOTIC OF CHOICE FOR SEVERE

MALARIA
Classify Fever: High or Low Malaria Risk

GIVE ONE DOSE OF PARACETAMOL FOR

FEVER
Classify Fever: High or Low Malaria Risk

PINK CLASSIFICATION
Classify Fever: High or Low Malaria Risk

STIFF NECK
Classify Fever: High or Low Malaria Risk

GIVE QUININE FOR THIS CLASSIFICATION

Classify Fever: High or Low Malaria Risk

GIVE QUININE FOR THIS CLASSIFICATION

Classify Fever: High or Low Malaria Risk

GREEN CLASSIFICATION
Classify Fever: High or Low Malaria Risk

REFER URGENTLY TO THE HOSPITAL

No Malaria Risk and No travel to Malaria risk areas
No Malaria Risk and No travel to Malaria risk areas

NO GENERAL DANGER SIGNS

No Malaria Risk and No travel to Malaria risk areas

NO STIFF NECK
No Malaria Risk and No travel to Malaria risk areas

STIFF NECK
No Malaria Risk and No travel to Malaria risk areas

FOLLOW UP IN TWO DAYS IF

FEVER PERSISTS
If Measles now or within last 3 months…
If Measles now or within last 3 months…

ANY GENERAL DANGER SIGNS

If Measles now or within last 3 months…

GIVE FIRST DOSE OF

APPROPRIATE ANTIBIOTIC
If Measles now or within last 3 months…

MEASLES
If Measles now or within last 3 months…

SEVERE COMPLICATED
MEASLES
If Measles now or within last 3 months…

MEASLES WITH EITHER EYE OR

MOUTH COMPLICATIONS
If Measles now or within last 3 months…

GIVE VITAMIN A TREAMENT

If Measles now or within last 3 months…

ANTIBIOTIC OF CHOICE FOR

PUS IN THE EYE
If Measles now or within last 3 months…

TREATMENT FOR MOUTH

ULCER
If Measles now or within last 3 months…

CLOUDING OF CORNEA
If Measles now or within last 3 months…

LETHARGY
If Measles now or within last 3 months…

PINK CLASSIFICATION
If Measles now or within last 3 months…

YELLOW CLASSIFICATION
If Measles now or within last 3 months…

GREEN CLASSIFICATION
If Measles now or within last 3 months…

REFER URGENTLY TO THE

HOSPITAL
Classify Ear Problem
Classify Ear Problem

NO EAR PAIN
Classify Ear Problem

NO TREATMENT
Classify Ear Problem

NO PUS IN THE EAR

Classify Ear Problem

NO EAR INFECTION
Classify Ear Problem

PUS IN THE EAR FOR LESS

THAN 14 DAYS
Classify Ear Problem

PUS IN THE EAR FOR MORE

THAN 14 DAYS
Classify Ear Problem

GIVE ANTIBIOTIC FOR 5

DAYS
Classify Ear Problem

GIVE ANTIBIOTIC FOR 5

DAYS
Classify Ear Problem

DRY THE EAR BY WICKING

Classify Ear Problem

TREAT WITH TOPICAL

QUINOLONE FOR 14 DAYS
Classify Ear Problem

ACUTE EAR INFECTION

Classify Ear Problem

CHRONIC EAR INFECTION

Classify Ear Problem

TENDER SWELLING BEHIND

THE EAR
Classify Ear Problem

MASTOIDITIS
Classify Ear Problem

ANTIBIOTIC OF CHOICE FOR

MASTOIDITIS
Classify Ear Problem

REFER URGENTLY TO THE

HOSPITAL
Classify Anemia
Classify Anemia

SEVERE ANEMIA
Classify Anemia

SEVERE PALMAR PALLOR

Classify Anemia

SOME PALMAR PALLOR

Classify Anemia

ANEMIA
Classify Anemia

GREEN CLASSIFICATION
Classify Anemia

REFER URGENTLY TO THE

HOSPITAL
COMMUNICABLE DISEASES
JAIDEE R. ROJAS, RN
TOPRANK REVIEW ACADEMY
COMMUNICABLE DISEASES
• Caused by infectious agent (whether bacteria or virus)
• Contagious- easily transmitted
• Airborne or droplet
• Infectious- not easily transmitted
• Blood borne, food borne, STDs

`“All contagious diseases are infectious, but not all

infectious diseases are contagious.”
CHAIN OF INFECTION
MAIN ROUTES OF TRANSMISSION
• Direct contact transmission
• Through direct body contact with the tissues or fluids of an
infected individual.
• Physical transfer and entry of microorganisms occurs through
mucous membranes (e.g., eyes, mouth), open wounds, or
abraded skin.
• Indirect contact transmission
• Involves contact between a person and a contaminated
object.
• This is often a result of unclean hands contaminating an
object or environment.
MAIN ROUTES OF TRANSMISSION
• Droplet
• Transmission occurs when droplets containing
microorganisms generated during coughing, sneezing and
talking are propelled through the air.
• Relatively large and travel only short distances (up to 6 feet/2
metres).
• These infected droplets may linger on surfaces for long
periods of time
MAIN ROUTES OF TRANSMISSION
• Airborne
• Droplet nuclei (small particles of 5 mm or smaller in size)
• Dust particles containing infectious agents. Microoganisms
carried in this manner remain suspended in the air for long
periods of time and can be dispersed widely by air currents.
MAIN ROUTES OF TRANSMISSION
• Vehicle route
• Food
• Water
• Blood

• Vector borne
• Aedes mosquito: Zika, Chikungunya virus
• Anopheles mosquito: Filariasis, Malaria
• Culex mosquito: Japanese Encephalitis
 Diphtheria
• Causative agent: Corynebacterium diphtheria or Klebbs-
loffler
• Mode of transmission: Droplet especially secretions from
mucous membranes of the nose and nasopharynx and
from skin and other lesions; Milk has served as a vehicle

• Incubation Period: 2 – 5 days

 Diphtheria
• SIGNS AND SYMPTOMS:
• Respiratory Diphtheria
• Sore throat, Fever
• Difficulty swallowing
• Bull neck appearance
• Pathognomonic sign: Pseudomembrane
(A thick, gray membrane covering the throat and tonsils.)
 Diphtheria
• SIGNS AND SYMPTOMS:

• Laryngeal Diphtheria
• Gradually increasing hoarseness, cough, stridor
• Nasal Diphtheria
• Clear nasal discharge but every becomes blood stained
• Cutaneous Diphtheria
• Skin ulcers commonly in the legs
 Diphtheria
• Diagnostic test:
• Nose/throat swab
• Moloney’s test – a test for hypersensitivity to diphtheria toxin
• Schick’s test – determines susceptibility to bacteria

• Interventions:
ü Isolate the child until two negative nose and throat culture are
negative (24 hours apart)
üBed rest is necessary (except for nasal diphtheria)
üOral hygiene (warm mouth wash, NEVER TOOTHBRUSH)
 Diphtheria
• Prevention:
üActive immunization: DPT immunization
üPassive immunization: Anti-toxin

• Drug-of-Choice: Erythromycin 20,000 - 100,000 units IM

once only
• Complication: MYOCARDITIS
 Pertussis
• “Whooping cough”
• Causative agent: Bordetella pertussis; Hemophilus
pertussis; Bordet-gengou bacillus; Pertussis bacillus
• Mode of transmission: Droplet especially from laryngeal
and bronchial secretions
• Incubation Period: 7 – 10 days but not exceeding 21 days
 Pertussis
• Three stages:
1. Catarrheal or Prodromal stage:
1. 7-14 days
2. Mild fever, headache, colds
3. Persistent cough
2. Paroxysmal stage (Spasmodic or whooping stage)
1. 14-28 days
2. Paroxysmal cough (Several sharp coughs in one expiration, followed by deep inspiration, which
may be accompanied by. Whoop)
3. Cough is worse at night
4. Anorexia
3. Convalescent stage:
1. Lasts 21 days
2. Less cough and vomiting
 Pertussis
• Diagnostic:
• Bordet-gengou agar test

• Management:
• Drug of choice: Erythromycin or Penicillin 20,000 - 100,000
units
• Isolation and complete bed rest
• For paroxysmal stage: Avoid dust pollutants, oxygenation, calm
atmosphere
• Watch out for airway obstructions
 Pertussis
• Prevention:
• Active immunization: DPT immunization
• Booster: 2 years and 4-5 years
• Patient should be segregated until after 3 weeks from the
appearance of paroxysmal cough

• Passive immunization: Gamma globulin

 Tetanus
• “Lock jaw”
• Etiologic agent: Clostridium tetani – anaerobic spore-forming heat-
resistant and lives in soil or intestine
• Neonate: umbilical cord
• Children: dental caries
• Adult: punctured wound; after septic abortion

• Mode of transmission: Indirect contact – inanimate objects, soil,

street dust, animal and human feces, punctured wound

• Incubation Period: Varies from 3 days to 1 month, falling between 7

– 14 days
 Tetanus
• Signs and symptoms

• Convulsion is the first warning symptom among children

• Restlessness and irritability

• Muscular stiffness progresses

• Trismus : Tight jaw, inability to open mouth
• Stiff arm and legs, then whole body
• Resus sardonicus: Facial muscle spasm
• Opisthotonus: Backward arching of the back as a result of dominance
of extensor muscles of the spine, head draws back.
 Tetanus
• No specific test, only a history of punctured wound
• Treatment:
• Antitoxin antitetanus serum (ATS)
• Tetanus immunoglobulin (TIG) (if the patient has allergy, should be administered in fractional
doses)
• Antibiotics (Penicillin G)
• Diazepam – for muscle spasms
• Prevention:
• Active immunization: DPT immunization
• Tetanus toxoid (artificial active) immunization among pregnant women
• Passive immunization: Tetanus immuno-globulin or antitoxin
 Poliomyelitis
• “Infantile paralysis”

• Causative agent: Poliovirus (Legio debilitans)

• Man is the only reservoir

• Mode of transmission: Fecal – oral

• Incubation period: 5-14 days

 Poliomyelitis
• Signs and symptoms:
• Abortive Poliomyelitis
• Upper respiratory tract infection symptoms
• Fever, Headache, Vomiting
• Non-Paralytic polio
• Stiffness of neck, back and limbs
• Nausea and vomiting
• Increase protein in CSF
• Paralytic Polio
• Spinal: Paralysis appear within a day or two after above manifestations; Limb paralysis most
common; chest, diaphragm, bladder and bowel paralysis may also occur.
• Bulbar Polio
• Life threatening; swallowing problem and regurgitation; aspiration may occur; Encephalitis
 Poliomyelitis
• Diagnostic test:
• CSF analysis / lumbar tap
• Management:
• Rehabilitation involves ROM exercises
• Symptomatic

Prevention:
• Active immunization: OPV, IPV vaccination (Trivalent poliovirus vaccine)
• Sabin: Attenuated; Orally
• Salk: Killed virus; Injection
• Passive immunization: Gammaglobulin
 Measles
• “Morbilli Rubeola”
• Causative agent: RNA containing paramyxovirus
• Period of Communicability: 4 days before the appearance of rash to
5 days after rash appearance
• Mode of transmission: Airborne -droplet secretions from nose and
throat
• Incubation period: 10 days – fever ;14 days – rashes appear (8-13
days)
 Measles
• Coryza
• Common colds and occur before rash appearance
• Fever (Highest just before the appearance of the rash)
• Barking cough
• Conjunctivitis and photophobia; Enlarged posterior cervical lymph nodes
• Koplik’s spots: Appear on day before rash. Whitish spots with reddish base on the
inside of the mouth
• Rash: Appears on 2nd to 5th day and remain about a week
• Appears first on the face, behind the ears, on the neck, forehead or cheeks
then spread downwards over the rest of the body (Trunk, arms, legs)
• Itchy rash
 Measles
• No specific diagnostic test
• Management:
• Isolation and bed rest.
• Supportive and symptomatic
• Eye care with warm saline solution
• Antipyretics for fever; Encourage fluids
• Mouth care for Koplik’s spots

• Prevention:
• Active immunization: Live attenuated vaccine
• Passive immunization: Newborn through the mothers; Gamma globulin
• Disinfection of soiled articles Isolation of cased from diagnosis until about 5-7 days
after onset of rash
 Mumps
• Etiology: Paramyxovirus

• Incubation Period: 14-21 days

• Communicability Period: One to six days before the first

symptoms appears until swelling disappears

• Mode of transmission: Droplet; Direct or indirect contact

 Mumps
• Prodromal Phase:
• Coryza’
• Low grade fever
• Vomiting, headache, malaise

• Acute Phase:
• Pain in or behind ears; Pain on swallowing or chewing
• Swelling and pain in glands (unilateral or bilateral)
• Orchitis and mastitis may occur

• Complication: Sterility
 Mumps
• Management:
• Symptomatic treatment
• Isolation and bed rest until swelling disappears
• Encourage fluids and soft foods
• Apply hot or cold compress for swelling.
• Orchitis: Support scrotum, use cold compress for 20 minutes.

• Prevention:
• Active immunization: Live attenuated vaccine
• Passive immunization: Gamma-globulin
 Chicken Pox
• Etiologic agent: Varicella-zoster virus

• Period of Communicability: From as early as 1 to 2 days before the

rashes appear until the lesions have crusted.

• Mode of transmission: Airborne

• Incubation Period: 2-3 weeks, commonly 13 to 17 days

 Chicken Pox
• Prodromal stage:
• Mild fever, anorexia, headache
• Acute Phase:
• Vesiculo-pustular rashes
• Centrifugal appearance of rashes – rashes which begin on the
trunk and spread peripherally and more abundant on covered
body parts
• Pruritus
 Chicken Pox
• No specific diagnostic exam
• Treatment is supportive.
• Drug-of-choice: Acyclovir / Zovirax ® (orally to reduce the number of
lesions; topically to lessen the pruritus)
• To relive itching, antihistamine, or calamine lotion.
• Cool sponge bath. Mittens may be used to avoid scratching
• Keep in isolation until lesions have been crusted.
• NEVER give ASPIRIN. Aspirin when given to children with viral
infection may lead to development of REYE’S SYNDROME.
 German measles
• “Rubella”
• Causative agent: Rubella virus or RNA containing Togavirus
(Pseudoparamyxovirus)
• Teratogenic infection, can cause congenital heart disease
and congenital cataract.
• Mode of transmission: Droplet, Direct/ Indirect contact
• Incubation Period: 14-21 days
• Communicable Period: During Prodromal period and 5
days after the rash.
 German measles
• Prodromal stage:
• Mild fever (Disappears when rash appear)

• Malaise, headache, anorexia

• Runny nose, sore throat

• Forscheimer spots – red pinpoint patches on the oral cavity

• Faint maculopapular rashes. Small pinpoint pink or pale red macules which
fades on pressure.

• Enlargement of posterior cervical and postauricular lymph nodes

 German measles
• Diagnostic Test: Rubella Titer (Normal value is 1:10); below
1:10 indicates susceptibility to Rubella.
• Instruct the mother to avoid pregnancy for three months after
receiving MMR vaccine.
• MMR is given at 15 months of age and is given intramuscularly.

• Prevention:
• MMR vaccine (live attenuated virus) - Derived from chick
embryo
Contraindication: Allergy to eggs