IMNCI Integrated Management of Newborn and Childhood Illness

INTRODUCTION: Over the past quarter century, child mortaity has more than halved, dropping from
91 to 43 deaths per 100 live births between 1990 and 2015. Yet in 2015 an estimated 5.9 million children
still died before reaching their 5th birthday. IMNCI was 1st developed in 1992 by UNICEF and the World
Health Organization (WHO) with the aim of prevention, or early detection and treatment of the leading
childhood killers. IMNCI seeks to reduce childhood mortality and morbidity by improving case
management of skills of health workers in the wider health system. The child mortality and morbidity
occurs due to acute respiratory infections, diarrhea, measles, malaria, malnutrition.

DEFINITION:

• It is an integrated approach to child health that focuses on the well being of the whole child. It
aims to reduce death , illness and disability and to promote improved growth and development
among under 5’s. It includes both preventive and curative elements that are implemented by
families , communities and health facilities.

• IMNCI is an integrated approach to child health that focuses on the wellbeing of the
whole child. IMNCI aims to reduce death , illness and disability, and to promote improved growth
and development among children under five years of age.

• IMNCI is an integrated approach to child health that focuses on the well being of the whole child.
It focussed primarily on the most common causes of child mortality – diarrhea , pneumonia ,
measles , malaria , and malnutrition , illness affecting children aged 1 week – 2 nnnnmonths , 2
months -5 year including both preventive and curative elements to be implemented by families.

• IMNCI is a strategy that integrates all available measures for health promotion, prevention and
integrated management of childhood diseases through their early detection and effective treatment
, and promotion of healthy habits within the family and community.

The strategy includes three main components:

1. Improving family and community health practices.

2. Improving overall health systems.
3. Improving case management skills of health-care staff.

• IMNCI is an integrated approach to child health that focuses on the well-being of the whole child
, aims to reduce death , illness and disability, and to promote improved growth and development
among children under five years of age. It includes both preventive and curative elements that are
implemented by families and communities as well as by health facilities.
 Features of IMCI

o Manages most common diseases (pneumonia, diarrhea, measles, malaria, dengue, malnutrition,
anemia, ear problems)
o Includes preventive interventions i.e immunisation.
o Adjusts curative interventions to the capacity and function of the health system.
o Involves family and community in the process.

Goals of IMNCI

❖ Standardized case management of sick newborns and children.

❖ Focus on the most common causes of mortality.
❖ Nutrition assessment and counselling for all sick infants and children.
❖ Home care for newborn to-
- promote exclusive breastfeeding
- prevent hypothermia
- improve illness recognition & timely care seeking

Essential components of IMNCI

• Improve health and nutrition worker’s skills

• Improve health systems
• Improve family and community practices

Major Adaptations

▪ The entire 0-5 year period covered including the 1st week of life
▪ 50% of training time for management of young infants (0-2 months)
▪ The order of training reversed ; now begins with managements of young infants
▪ Reduced training duration (8 days) , separate training materials for physicians & health workers
▪ Management now consistent with current policies of the MoHFW, DWCD and NAMP
▪ Home - based care of young infants by health workers added

Principles of IMNCI

1. All sick children must be examined for “ general danger signs ” which indicate the need for
immediate referral or admission to a hospital.

2. All sick children must be routinely assessed for major symptoms ( for children age 2 months upto
5 years: cough or difficult breathing , diarrhoea , fever , ear problems (for young infants upto 2
months: very severe disease , diarrhoea , jaundice and feeding.

3. They must also be routinely assessed for nutritional and immunization status , feeding problems
and other problems.
 4. Assess vitamin A supplementation and deworming status for children age 2 months upto 5 years.

Beneficiaries of IMNCI

Newborns and infants (under 2 months)

Young children (2 months – 5 years)

CARE OF NEWBORNS AND YOUNG INFANTS

• Keep the child warm

• Initiation of breast feeding
• Counselling of mother for exclusive breast feeding
• Cord , skin and eye care
• Recognition of illness in newborn and its management
• Immunization
 CHECK FOR OTHER PROBLEMS
Classify the condition of the child and assign to one of the three colour codes
Identify the treatment actions as per the actions listed in that colour band

URGENT REFERRAL TREAT AT THE OPD HOME MANAGEMENT

1. Pre-referral treatments 1. Treat local infection Counsel care taker on how to:
2. Advice parents 2. Give oral drugs 1. Give oral drugs
3. Refer the child 3. Advise and teach mother 2. Treat local infections at
4. Follow-up home
At The Referral Facility 3. Continue feeding
4. Danger signs
1. ETAT ( Emergency 5. Follow-up
Triage Assessment and
Treatment )
2. Diagnosis, treatment and
3. Monitoring and follow up

IMNCI case management process:

The case management process is presented on a series of charts , which show the sequence of steps and
how to perform them.

The charts describe the following steps

1. Assess the young infant or child

• Means taking a history and doing a physical examination.

2. Classify the illness

 • Means making a decision on the severity of the illness and
• Assigning to a colour, or “ classification,” which corresponds to the severity of the disease
• Classifications are not specific disease diagnoses. Instead, they are colour coded categories that
are used to determine treatment

3. Identify treatment

The charts recommend appropriate treatment for each colourcoded classification

4. Treat the infant or child

“ Treat ” means giving treatment in clinic,

• prescribing drugs or other treatments to be given at home, and

• also teaching the motherhow to carry out the treatments.

5. Counsel the mother

• assessing how the child is feed and

• telling her about the foods and fluids to give the child and
• when to bring the child back to the clinic

6. Give follow - up care

IMNCI ASSESSMENT STEPS, AGE BIRTH UPTO 2 MONTHS

YOUNG INFANTS

Birth Asphyxia

Prematurity and Low Birth Weight

Possible serious Bacterial Infection & Jaundice Diarrhea

HIV infection

Feeding Problem or Low Weight

Immunization status

Assess other problems

NEWBORN CARE DURING 1st WEEK ( 0-6 DAYS )

• Essential Newborn Care at birth

- Drying / covering & assessment of breathing / color
- Early skin – skin contact and breast feeding
- Cord & eye care ; Vitamin K
• Assessment & Management of Birth Asphyxia
• Assessment & Management of Prematurity and LBW
Feeding & Temperature ( Kangaroo Mother Care )

ASK

▪ Has the infant had convulsion?

▪ Is the infant not feeding?

LOOK , LISTEN , FEEL :

▪ Count RR and look for severe chest indrawing.

▪ Look and listen for grunting.
▪ Look for feel for bulging fontanelle.
▪ See if the infant is not feeding; or is convulsing now
▪ Measure temperature ( or feel for fever or low body temp. )
▪ Look at the umbilicus & for skin pustules.
▪ Look at the young infant’s movements – Are they less than normal?
▪ Look for Jaundice:
Are the palms and soles yellow ?
Are skin on the face or eyes yellow ?
CLASSIFICATION OF POSSIBLE SERIOUS BACTERIAL
INFECTIONS

SIGNS CLASSIFY AS IDENTIFY TREATMENT

(URGENT PRE-REFERRAL
TREATMENTS ARE IN
BOLD PRINT)
• Not feeding well or POSSIBLE ▪ Give 1st dose of
• Convulsion / convulsing now or SERIOUS intramuscular Ampicillin
• Fast breathing (60 breaths per BACTERIAL and Gentamycin
minute or more ) or INFECTION ▪ Treat to prevent low blood

• Severe chest indrawing or OR sugar

• Grunting or VERY SEVERE ▪ Warm the young infant by

• Fever ( 37.5℃ or above or feels DISEASE skin-to-skin contact if

hot ) or temperature is less than

36.5℃ ( or feels cold to
• Movement only when stimulated
touch ) while arranging
or no movement even when
referral
stimulated.
▪ Advise mother how to
keep the young infant
warm on the way to the
hospital
▪ Refer URGENTLY to
hospital
 • Red umbilicus or draining pus or LOCAL • Give Clotrimazole or
• Skin postules BACTERIAL Amoxycillin for 5 days
INFECTION • Teach the mother to treat
local infection at home
• Advise mother when to
return immediately
• Follow - up in 2days
• Palms and / or soles yellow SEVERE • Treat to prevent low blood
• Age < 24hours JAUNDICE sugar
• Age 14 days or more • Warm the young infant by
skin-to-skin contact if
temperature is less than
36.5℃ ( or feels cold to
touch ) while arranging
referral
• Advise mother how to
keep the young infant
warm on the way to the
hospital
• Refer URGENTLY to
hospital
• Only skin or eyes yellow JAUNDICE • Advise mother to give
home care for the young
infant
• Advise mother when to
return immediately
• Follow - up in 2days

Diarrhea in Young infants

1. Relatively rare compared to the older child.

2. Assessment , classification & management the same to the sick child except.
 3. All bloody and persistant diarrheas are referred to hospital for management.

HIV INFECTION IN YOUNG INFANTS

Sign Classify Treatment

• Positive PCR test in the young Confirmed • Give Clotrimazole Prophylaxis
infant HIV from 6 weeks of age
Infection • Assess feeding and counsel as
necessary
• Advise the mother on home care

• Mother HIV positive, Possible • Assess feeding and counsel as

• Child has positive HIV antibody HIV necessary
test infection • Give Clotrimazole Prophylaxis
(HIV from 6 weeks of age
exposed) • Confirm HIV status as soon sas
possible using PCR
• Follow – Up 14 days
Negative HIV test in mother or child HIV Treat, counsel and follow existing
infection infections
unlikely Advise the mother about feeding and
about her own health

CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

 Sign Classify as Treatment

If any of the following signs: • Advise the mother to breastfeed

• Not well positioned or as often and for as long as the
• Not well attached to breast or infant wants, day and night
• Not sucking effectively or • If not well attached or not
• Less than 8 breastfeeds in 24 sucking effectively , teach
hours or correct positioning and
• Switching the breast frequently attachment
or Feeding Problem • If breastfeeding less than 8 times
• Not increasing frequency of Or in 24 hours, advie to increase
breastfeeding during illness or Low Weight frequency of feeding

• Receives other foods or drinks • Empty one breast completely

or before switching to the other

• The mother not breastfeeding at • Increase frequency of feeding

all or during and after illness

• Low weight for age or If not breastfeeding at all :

• Thrush ( ulcers or white patches - Refer for breastfeeding

in mouth ) counselling and possible

relactation
- Advise about correctly
preparing breast milk
substitute and using a cup
- If thrush , teach the mother to
treat thrush at home
- Advise mother to give home
care for the young infant
- Follow – up any feeding
problemor thrush in 2 days
- Follow – up low weight for
age in 14 days

Now low weight for age and no No feeding - Advise mother to give home care
other signs of inadequate feeding Problem the young infant
 - Praise the mother for feeding the
infant well

o Check immunization status for the child.