integrated management of neonatal and childhood illness(IMNCI)

Integrated Management of Neonatal &

Childhood Illness(IMNCI)

SPEAKER:- Shubhanshu Gupta

TEACHER I/C:- Dr.Dheeraj Mahajan

DATE:- 21/10/2014

1

Contents

• Introduction

• IMNCI

- Components

- Guidelines

- Principles Of Integrated Care

- Elements Of Case Management Process

- Case Management Process

• F- IMNCI

• C-IMNCI

• IMNCI plus

• IMNCI in UP(CCSP)

2

Introduction

• Every year more than 10 million children die in developing

countries before they reach their fifth birthday.

• 7 in 10 of these deaths are due to five preventable and treatable

conditions.

Pneumonia, diarrhea, malaria, measles and malnutrition – and

often to a combination of these conditions.

• 3 out of 4 of these children suffer from one of these five

conditions.3

4

• Almost 19,000 children under 5 yrs of age, died everyday across the

world. 50% of it occurs in just five countries i.e. India, Nigeria,

Congo, Pakistan and China.

• In India, there are nearly 16.55 lakhs child deaths during 2011 and

we rank top among the countries with highest child mortality.

• India IMR-42/1000 live births. (46 – Rural, 28 - Urban) in 2012,which was 47 in 2010.

World IMR-35/1000 live births

• India PMR=32,NMR=33,U5MR=59 per 1000 live births.

• In INDIA- M.P. has the highest IMR followed byASSAM,ORISSA and UP.

MP=56,ASSAM=55,ORISSA and UP=53/1000 live births. 5

• Projections based on the 1996 analysis indicate that common childhood illnesses will continue to be major contributors to child deaths through the year 2020 unless greater efforts are made to control them.

• This assumption makes a strong case for introducing new strategies to significantly reduce child mortality and improve child health and development.

• WHO and UNICEF recognized the need to strengthen child-health activities in the country and decided to launch IMCI.

• The generic IMCI guidelines were adapted and the Indian version was named Integrated Management of Neonatal and Childhood Illness (IMNCI)-main intervention under RCH-II/NRHM ,that focuses on preventive,promotive and curative aspects of program.

6

Why Newborn in India1st Hour 1st Day 1st Week 1st Month

Reasons for the delay in assessment and accessibility of newborn to reach healthcare setting:

1.Starting of a problem

2. Delay in recognizing problem

3.Home based treatment

4.Delay in selecting health facility

5.Treatment from traditional advisors and village doctors

6.Delay in selecting formal health facility causing delay in treatment and increased cost

7.Increased chances of death of newborn.

7

8

What is IMNCI ?

• IMNCI is an integrated approach to child health that focuses on the

well-being 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 includes both preventive and curative elements that are

implemented by families and communities as well as by health

facilities.

•The strategy includes three main components:

Improving case management skills of health-care staff

Improving overall health systems

Improving family and community health practices.

9

Difference between IMCI and IMNCIFeatures: WHO – UNICEF IMCI IMNCI

Coverage of 0 to 6 days (early

newborn period)

No Yes

Basic Health Care Module NO Yes

Home visit by the provider for

newborn and Young Infant

No Yes

Training

Training Home based Care No Yes

Training days for newborn and

young infants

2 out of 11 days 4 out of 11 days

Sequence of training Child (2 months to 5 years of

age) then Young infant ( 7 days

to 2 months of age)

Newborn and young infants (0

to 2 months).Then Child (from

2 months to 5 years of age.)

10

Evidence-based, syndromic approach to case management includes rational, effective

and affordable use of drugs and diagnostic tools.

An evidence-based syndromic approach can be used to determine the:

• Health problem(s) the child may have.

• Severity of the child’s condition, and

• Actions that can be taken to care for the child (e.g. refer the child immediately,

manage with available resources, or manage at home).

In addition, IMNCI promotes:

•Adjustment of interventions to the capacity of the health system, and

•Active involvement of family members and the community in the health care process.

11

Guidelines for IMNCI

IMCI Process:

12

Principles of integrated care

• All sick young infants up to 2 months of age must be assessed for

“possible bacterial infection / jaundice”. Then they must be

routinely assessed for the major symptom “diarrhoea”.

• All sick children age 2 months up to 5 years must be examined for

“general danger signs” which indicate the need for immediate

referral or admission to a hospital. They must then be routinely

assessed for major symptoms: cough or difficult breathing,

diarrhoea, fever and ear problems.

• All sick young infants and children 2 months up to 5 years must

also be routinely assessed for nutritional and immunization status,

feeding problems, and other potential problems.13


(Contd. .)

A combination of individual signs leads to a child's classification(s)

rather than diagnosis.

- needs urgent hospital referral or admission

( classifies as and colour coded pink)

- needs specific medical Rx or advice

(classified as and colour coded yellow)

- can be managed at home

(classified as and colour coded green)

14


(Contd. .)

• IMNCI use a limited number of essential drugs and encourage

active participation of caretakers in the treatment.

• IMNCI address most, but not all, of the major reasons a sick child

is brought to a clinic.

• One of essential component of IMNCI is the counselling of

caretakers about home care,feeding,fluids and when to return to

health facility. 15

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 newborns to

– promote exclusive breastfeeding

– prevent hypothermia

– improve illness recognition & timely care seeking

16

Elements of case management

process

• Assess - Child by checking for danger signs by history and

examination.

• Classify - Child's illness by color coded triage system.

• Identify - Specific treatments.

• Treatments- Instructions of oral drugs, feeding & fluids.

• Counsel - Mother about breast feeding & about her own health as

well as to follow further instructions on further child care.

• Follow up care - Reassess the child for new problems.17

The CASE MANAGEMENT PROCESS Is Used To

Assess And Classify Two Age Groups

Management Of The Young Infant Age Up To 2

Months Is Presented On Two Charts

Assess and classify the sick young infant age up to 2 months.

Treat the young infant and counsel the mother.

18

Assess and classify the sick young

infant up to 2 months

19

ASK:-•Has the infant had convulsions ?

LOOK ,LISTEN ,FEEL:-•Count the breaths in one minute .repeat the count

•Look for severe chest indrawing

•Look for nasal flaring

•Look and listen for grunting

•Look and feel bulging fontanelle

•Look for pus draining from the ear

•Look at the umbilicus-is it red or draining pus ?

•Look for skin pustules. Are there 10 or more skin pustules or a big boil

•Measure axillary temp.

•See if the young infant is lethargic or unconscious

•Look at the young infant’s movements. Are they less than normal?

•Look for jaundice. Are the palms and soles yellow?

20

SIGNS CLASSIFY

AS

IDENTIFY TREATMENT

•Convulsions or

•Fast breathing(60 breaths per

minute or more)

•Severe chest indrawing

•Nasal flaring

•Grunting

•Bulging fontanelle

•10 or more skin pustules or a

big boil If axillary temp>=

37.5 or temp<=35.5 degree

celsius

•Lethargic or unconscious

•Less than normal movements

POSSIBLE

SERIOUS

BACTERIAL

INFECTION

Give first dose of

intramuscular ampicillin and

gentamicin

Treat to prevent low blood

sugar

Warm the young infant by skin

to skin contact if temperature less

than 36.5°C (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.21

•Umbilicus red or

draining pus

•Pus discharge from ear

or

•< 10 skin pustules

LOCAL

BACTERIAL

INFECTION

Give oral co-

trimoxazole or

amoxycillin for 5

days

Teach mother to treat

local infections at

home

Follow up in two

days

Umbilicus redDraining

pus

22

SIGNS CLASSIFY AS IDENTIFY

TREATMENT

•Palms &soles yellow

•Age <24hrs or

•Age >=14 days

SEVERE JAUNDICE Treat to prevent low blood sugar

Warm the young infant by skin to

skin contact if temperature less than

36.5°C (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

•Palms& soles not

yellow

JAUNDICE Advise mother to give home care for

the young infant

Advise mother when to return

immediately

Follow up in 2 days

23

•Temperature

between 35.5-

36.4degree Celsius

LOW BODY

TEMPERATURE

Warm the young infant by

skin contact for 1 hr and

REASSESS

Treat to prevent low

blood sugar

24

ASK:-•Does the child have diarrhea?

• IF YES THEN , FOR HOW LONG?

LOOK AND FEEL:-•Look at the general conditions. Is he/she

-lethargic or unconscious?

-restless and irritable?

•Look for sunken eyes

•Pinch the skin of abdomen ,

and notice how it goes back:

-very slowly( longer than two seconds)?

-slowly?

-immediately? 25

Classification:

Signs Classify treatment

Two of the

following

signs:

Lethargic or

unconscious

Sunken eyes

Skin goes back

very slowly

SEVERE

DEHYDRATION

If infant has low weight or another severe

classification:

Give first dose of intramuscular ampicillin

and gentamicin

- Refer URGENTLY to hospital with

mother giving frequent sips of ORS on the

way

- Advise mother to continue breast feeding

- Advise mother to keep the young infant

warm on the way to the hospital

ORIf infant does not have low weight or any

other severe classification:- Give fluid for severe dehydration (Plan C) and then refer tohospital after rehydration

26

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•Not enough signs to

classify as some or

severe dehydration

NO

DEHYDRATION

Give fluids to treat diarrhea at

home(PLAN A)

Advise mother when to return

immediately

Follow up in 5 days if not

improving

Two of the following

signs for

restless, irritable

sunken eyes

skin pinch goes

back slowly

SOME

DEHYDRATION

Give first dose of intramuscular

ampicillin and gentamicin.

Give fluids to treat some

dehydration(PLAN B)

Refer URGENTLY to hospital

with mother giving frequent oral

sips of ORS.

27

•Diarrhea lasting 14 days

or more

SEVERE

PERSISTENT

DIARRHOEA


ampilicin and gentamicin if infant has

low weight if the young infant has

low weight, dehydration or another

severe classification.

Refer to hospital

Advise to keep the baby warm

Treat to prevent low blood sugar

•Blood in the stools SEVERE

DYSENTERY


ampilicin and gentamicin if infant

has low weight if the young infant

has low weight, dehydration or

another severe classification.

Refer to hospital

Advise to keep the baby warm

Treat to prevent low blood sugar

28

Ask the mother:-

Is there any difficulty in feeding?

Is the infant breastfed?If yes - how many times in 24 hours?

Does the infant usually receive any other food or drinks?

If yes - how often?What do you use to feed the infant?

29

Look , Feel:-

Determine weight for age-Mid Upper Arm Circumference(MUAC)

MUAC TAPE

30

Assess Breast Feeding :-

•Has the infant breastfed in previous hour?

•Is the infant able to attach?

To check attachment , look for:Chin touching breastMouth wide openLower lip turned outwardMore areola visible above than below .

31

• If the infant has not feed in the previous hour, ask the mother to put her infant to the breast. Observe her breastfeed for 4 minutes.

• If the infant was fed during the last hour, ask the mother if she can wait and tell you when the infant is willing to feed again.

• Is the infant able to attach?

no attachment at all , not well attached , good attachment

• Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?

not suckling at all

not suckling effectively

suckling effectively

32

• Clear a blocked nose if it interferes with breastfeeding

• Look for ulcers or white patches in the mouth(thrush)

If yes, look and feel for:

Flat or inverted nipples, or sore nipples

Engorged breasts or breast abscess

• Does the mother have pain while breastfeeding?

• Classify feeding as:

Not able to feed-serious bacterial infection or severe malnutrition

Feeding problem or low weight for age

No feeding problem

33

Immunization Status

CHECK IMMUNIZATION STATUS:

IMMUNIZATION SCHEDULE• Birth - BCG,OPV(0) HepB1• 6 weeks - DPT1, OPV1,

HepB2

34

Counsel The Mother

Advice mother to give home care for the

young infant:

Food and fluids

Breastfeed frequently as often and for as long as the infant wants.

Make sure the young infant stays warm at all times.

35

Follow-Up Visit

If the infant has Return for follow up in

•Local bacterial infection

•Jaundice

•Diarrhea

•Any feeding problem

•Thrush

2 days

•Low weight for age 14 days

36

When To Return Immediately

• If the young infant has any of this signs:

Breastfeeding or drinking poorly

Becomes sicker

Develops a fever or feels cold to touch

Fast breathing

Difficult breathing

Yellow palms and soles

Diarrhoea with blood in stool.

37

CHECK FOR POSSIBLE BACTERIAL INFECTION•Has the infant had convulsions?

•Count the breaths in one minute. _______ breaths per minute

Repeat if elevated ________ Fast breathing?

•Look for severe chest indrawing.

•Look for nasal flaring.

•Look and listen for grunting.

•Look and feel for bulging fontanelle.

•Look for pus draining from the ear.

•Look at umbilicus. Is it red or draining pus?

Does the redness extend to the skin?

•Fever (temperature 37.5 C or feels hot) or low body temperature

(below 35.5° C or feels cool).

•Look for skin pustules. Are there many or severe pustules?

•See if young infant is lethargic or unconscious.

•Look at young infant's movements. Less than normal?

DOES THE YOUNG INFANT HAVE DIARRHOEA?•For how long? _______ Days

•Is there blood in the stools?

Yes _____ No ______

•Look at the young infant's general condition. Is the infant: Lethargic

or unconscious?

Restless or irritable?

•Look for sunken eyes.

•Pinch the skin of the abdomen. Does it go back: Very slowly (longer

than 2 seconds)?

Slowly?

MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS

Name:___________ Age:___________ Weight:____________________kg________________________Temperature:_______________C

ASK: What are the infant's problems?__________________________________ Initial visit?_________________ Follow-up Visit?______________ASSESS (Circle all signs present) CLASSIFY

38

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

•Is there any difficulty feeding? Yes_____ No______

•Is the infant breastfed? Yes_____ No_____

•IfYes, how many times in 24 hours?_____ times

•Does the infant usually receive any

other foods or drinks? Yes_____ No_____

If Yes, how often?

•What do you use to feed the child?

ASSESS BREASTFEEDING:•Has the infant breastfed in the previous hour?

•Determine weight for age. Low _____ Not Low _____

If infant has not fed in the previous hour, ask the mother to put her

infant to the breast. Observe the breastfeed for 4 minutes.

•Is the infant able to attach? To check attachment, look for:

— Chin touching breast Yes _____ No

_____

— Mouth wide open Yes _____ No _____

— Lower lip turned outward Yes _____ No _____

— More areola above than below the mouth

Yes _____ No _____

no attachment at all not well attached good attachment

•Is the infant suckling effectively (that is, slow deep sucks,

sometimes pausing)?

not suckling at all not suckling effectively suckling effectively

•Look for ulcers or white patches in the mouth (thrush).

CHECK THE YOUNG INFANT'S IMMUNIZATION STATUSBCG DPT1 DPT2

OPV 0 OPV 1 OPV 2

Circle immunizations needed today. Return for next

immunization on:

(Date)

MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS

Name:___________ Age:___________ Weight:____________________kg________________________Temperature:_______________C

ASK: What are the infant's problems?__________________________________ Initial visit?_________________ Follow-up Visit?______________ASSESS (Circle all signs present) CLASSIFY

If the infant has any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or drinks, or is low weight for age AND has no indications to refer urgently to

hospital:

39

TREAT

Return for follow-up on _________________

Give any immunization/s needed today.40

ASSESS And CLASSIFY THE SICK CHILD

AGE From 2 Months Up To 5 YEARS

41

General Danger Signs

ASK:

• Is the child able to drink or

breastfeed?

• Does the child vomit

everything?

• Has the child had convulsions?

LOOK:

• See if the child is lethargic or

unconscious

42

Cough or Difficult Breathing?

IF YES, ASK:

• For how long?

LOOK, LISTEN, FEEL:

• Count the breaths in one minute.

2-12 months = fast breathing >/= 50/min

12 months-5yrs = fast breathing >/=

40/min

• Look for chest indrawing

• Look and listen for stridor

Classify COUGH or DIFFICULT BREATHING

43

•Any general danger

sign or

•Chest indrawing or

•Stridor in calm child.

SEVERE

PNEUMONIA

OR VERY

SEVERE DISEASE

•Give first dose of an appropriate

antibiotic.

•Refer URGENTLY to hospital.

•Fast breathing

PNEUMONIA

•Give an appropriate oral antibiotic

for 5 days.

•Soothe the throat and relieve the

cough with a safe remedy.

•Advise mother when to return

immediately.

•Follow-up in 2 days.

No signs of

pneumonia

or very severe

disease.

NO PNEUMONIA:

COUGH OR COLD

•If coughing more than 30 days,

refer for assessment.

•Soothe the throat and relieve the

cough with a safe remedy.

•Advise mother when to return

immediately.

Classification Table For Cough Or Difficult Breathing

SIGNS CLASSIFY AS IDENTIFY TREATMENT

44

DiarrheaDoes the child have diarrhea?

IF YES, ASK:

•For how long?

•Is there blood in the stool?

LOOK, LISTEN, FEEL:

Look at the child’s general condition, is

the child:

Lethargic or unconscious?


Look for sunken eyes

Offer the child fluid. Is the child:

Not able to drink or drinking poorly?

Drinking eagerly, thirsty?Pinch the skin of the abdomen.

Does it go back:

Very slowly (> than 2 secs)?

Slowly?45

Two of the following signs:

Lethargic or unconscious

Sunken eyes

Not able to drink or drinking

poorly

Skin pinch goes back very

slowly

SEVERE

DEHYDRATION

If child has no other severe classification:

— Give fluid for severe dehydration (Plan C).

OR

If child also has another severe classification:

— Refer URGENTLY to hospital with mother giving

frequent sips of ORS on the way.

Advise the mother to continue breastfeeding

If child is 2 years or older and there is cholera in

your area, give antibiotic for cholera.

Two of the following signs:

Restless, irritable

Sunken eyes

Drinks eagerly, thirsty

Skin pinch goes back slowly

SOME

DEHYDRATION

Give fluid and food for some dehydration (Plan B).

If child also has a severe classification:

— Refer URGENTLY to hospital with mother

giving frequent sips of ORS on the way.

Advise the mother to continue breastfeeding

Advise mother when to return immediately.

Follow-up in 5 days if not improving.

Not enough signs to

classify as some or

severe dehydration. NO

DEHYDRATION

Give fluid and food to treat diarrhoea at home (Plan A).


Follow-up in 5 days if not improving.

Classification Table For Dehydration

SIGNS CLASSIFY ASIDENTIFY TREATMENT

46

SIGNS CLASSIFY AS IDENTIFY TREATMENT

Classification Table For Persistent Diarrhoea and dysentery

47

Dehydration present SEVERE

PERSISTENT

DIARRHEA

Treat dehydration before

referral unless the child has

another severe classification.

Refer to hospital.

No dehydration PERSISTENT

DIARRHEA

Advise the mother on feeding

a child who has PERSISTENT

DIARRHOEA.

Follow-up in 5 days.

Blood in the stool Dysentery

Treat for 5 days with an oral antibiotic recommended for Shigella in your area.

Follow-up in 2 days.

FeverDoes the child have FEVER?

IF YES, decide the malaria risk: high or low

THEN ASK:

•For how long?

•If more than 7 days, has fever been

present every day?

•Has the child had measles within the

last 3 months?

LOOK AND FEEL:

Look for runny nose

Look or feel for stiff neck

LOOK FOR SIGNS OF MEASLES

has measles now or within the last 3 months

-Rash -Mouth ulcers

-Cough -Pus from eyes

-Runny nose -Clouding of cornea

-Red eyes 48

•Any general danger

sign or

•Stiff neck or

• bulging fontanelle VERY SEVERE

FEBRILE

DISEASE


antibiotic.

•Treat the child to prevent low blood

sugar.

•Give one dose of paracetamol in clinic

for high fever (38.5° C or above).


•Fever (by history or

feels hot or

temperature above

37.5

MALARIA

•Give oral antimalarials for HIGH

RISK MALARIA.

•Give one dose of paracetamol

•Advice mother when to return

immediately

•Follow up in 2 days

.


(Urgent pre-referral treatments are in bold print.)

Classification Table For High Malaria Risk

49

•Any general danger sign

or

•Clouding of cornea or

•Deep or extensive

mouth ulcers.

SEVERE

COMPLICATED

MEASLES***

•Give vitamin A.


antibiotic.

•If clouding of the cornea or pus

draining from the eye, apply tetracycline

eye ointment.


•Pus draining from the

eye or

•Mouth ulcers

MEASLES WITH

EYE OR MOUTH

COMPLICATIONS

***

•Give vitamin A.

•If pus draining from the eye, treat eye

infection with tetracycline eye ointment.

•If mouth ulcers, treat with gentian violet.


•Measles now or within

the last 3 months. MEASLES

•Give vitamin A.



Classification Table For Measles

(If Measles Now Or Within The Last 3 Months)

*** Other important complications of measles—pneumonia, stridor, diarrhoea, ear infection, and malnutrition—are classified in

other tables.

50

Ear Problem

Does the child have an EAR PROBLEM?

IF YES, ASK

•Is there ear pain?

•Is there ear discharge? If yes, for how long?

LOOK AND FEEL:

Look and pus draining from the ear

Feel for tender swelling behind the ear.

51

•Tender swelling

behind the ear. MASTOIDITIS


antibiotic.

•Give first dose of paracetamol for pain.


•Pus is seen draining

from the ear and

discharge is reported

for less than 14 days,

or

•Ear pain.

ACUTE EAR

INFECTION

•Give an oral antibiotic for 5 days.

•Give paracetamol for pain.

•Dry the ear by wicking.


•Pus is seen draining

from the ear and

discharge is reported

for 14 days or more.

CHRONIC EAR

INFECTION

•Dry the ear by wicking.


•No ear pain and No

pus seen draining from

the ear.

NO EAR

INFECTION

No additional treatment



Classification Table For Ear Problem

52

Malnutrition and Anemia

CHECK FOR MALNUTRITION AND

ANEMIA

LOOK AND FEEL:

• Look for visible severe wasting

• Look for palmar pallor. Is it:

• Severe palmar pallor?

• Some palmar pallor?

• Look for edema of both feet

• Determine weight for age

CLASSIFY NUTRITIONAL STATUS

53

•Visible severe wasting or

•Severe palmar pallor or

•Oedema of both feet.

SEVERE

MALNUTRITION

OR SEVERE

ANAEMIA

•Give Vitamin A.


•Some palmar pallor or

•Very low weight for age.

ANAEMIA OR VERY

LOW WEIGHT

•Assess the feeding

— If feeding problem, follow-up in 5 days.

•If pallor:

— Give iron.

— Give oral antimalarial if high malaria risk.

— Give mebendazole if child is 2 years or older and

has not had a dose in the previous 6 months.

•Advise mother when to return immediately.

•If pallor, follow-up in 14 days.

If very low weight for age, follow-up in 30 days.

•Not very low weight for

age and no other signs or

malnutrition.

NO ANAEMIA AND

NOT VERY LOW

WEIGHT

•If child is less than 2 years old, assess the

feeding and counsel the mother on feeding.

— If feeding problem, follow-up in 5 days.

•Advise mother when to return immediately.



Classification Table For Malnutrition And Anaemia

54

Immunization Status

CHECK IMMUNIZATION

STATUS:

IMMUNIZATION

SCHEDULE

• Birth - BCG, OPV 0

• 6 weeks - DPT1, OPV1,

HepB1

•10 weeks - DPT2,

OPV2,

HepB2

•14 weeks - DPT3, OPV3,

HepB3

•9 months – measles+ vit A

•16-18 months-DPTbooster,OPV

•60 months-DT55

Counselling a mother or caretaker

• Ask and Listen

• Praise

• Advice

• Check

Essential elements-

• Teach how to give oral drugs

• Teach how to treat local infection

• Teach how to manage breast or nipple problem

• Teach correct positioning and attachment for breastfeeding

• Counsel on other feeding problems

• Advise when to return

• Counsel the mother about her own health

56

How will you prepare the ORS solution? Do you remember how to mix the

ORS?

GOOD CHECKING QUESTIONS POOR QUESTIONS

How often should you breastfeed your child? Should you breastfeed your child?

On what part of the eye do you apply Have you used ointment on your child

the ointment? before?

How much extra fluid will you give after each Do you know how to give extra

loose stool? fluids?

Why is it important for you to wash your hands? Will you remember to wash your

hands?

57

Feeding Recommendations1. Upto 6 months-exclusive breast feeding

2. 6m-upto 12 m-breastfeed+ one katori serving*( 3 times/day if

breastfeed or 5 times/day if not breastfeed)

3. 12m-up to 2 yrs-breastfeed+food from family pot+one and a half

katori serving*(5 times/day)

4. 2 yrs and older- family food at 3 meals each day+ twice nutritious

food

*-mashed roti/rice/bread/biscuit mixed in sweet milk or in thick dal

with ghee or offer banana/mango/papaya or dalia/halwa/kheer in

milk58

If the child has: Return for follow-up in:

PNEUMONIA

DYSENTERY

MALARIA, if fever persists

FEVER—MALARIA UNLIKELY, if fever

persists

MEASLES WITH EYE OR MOUTH

COMPLICATIONS

2 days

PERSISTENT DIARRHOEA ACUTE EAR

INFECTION

CHRONIC EAR INFECTION

FEEDING PROBLEM

ANY OTHER ILLNESS, if not improving

5 days

VERY PALOR 14 days

LOW WEIGHT FOR AGE 30 days

Follow-up Visit Table In The Counsel The Mother Chart

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Advise to return immediately

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CHECK FOR GENERAL DANGER SIGNS

NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING

CONVULSION

LETHARGIC OR UNCONSCIOUS

General danger signs

present?

Yes ___ No ___Remember to use

danger sign when

selecting classifications

DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?

•For how long? ____ Days

Yes ___ No ___

•Count the breaths in one minute.

________ breaths per minute. Fast breathing?

•Look for chest indrawing.

•Look and listen for stridor.

DOES THE CHILD HAVE DIARRHOEA?

•For how long? _____ Days

•Is there blood in the stools?

Yes ___ No ___

•Look at the child's general condition. Is the child:

Lethargic or unconscious?


•Look for sunken eyes.

•Offer the child fluid. Is the child:

Not able to drink or drinking poorly?

Drinking eagerly, thirsty?

•Pinch the skin of the abdomen. Does it go back:

Very slowly (longer than 2 seconds)?

Slowly?

Name: ____________________________________________________________________Age:____________________Weight:_______kg Temperature:________ C

ASK: What are the child's problems?_______________________________________________________________________Initial visit?________________Follow-up Visit?__________

ASSESS (Circle all signs present) CLASSIFY

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

Decide Malaria Risk: High Low

•For how long? _____ Days

•If more than 7 days, has fever been present every day?

•Has child had measles within the last three months?

If the child has measles now

or within the last 3 months:

•Look or feel for stiff neck.

•Look for runny nose.

Look for signs of MEASLES:

Generalized rash and

One of these: cough, runny nose, or red eyes.

•Look for mouth ulcers.

If Yes, are they deep and extensive?

•Look for pus draining from the eye.

•Look for clouding of the cornea.

DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5 C or above) Yes ___ No ___

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DOES THE CHILD HAVE AN EAR PROBLEM?

•Is there ear pain?

•Is there ear discharge?

IfYes, for how long? ___ Days

Yes___ No___

•Look for pus draining from the ear.

•Feel for tender swelling behind the ear.

THEN CHECK FOR MALNUTRITION AND ANAEMIA •Look for visible severe wasting.

•Look for palmar pallor.

Severe palmar pallor? Some palmar pallor?

•Look for oedema of both feet.

•Determine weight for age.

Very Low ___ Not Very Low ___

CHECK THE CHILD'S IMMUNIZATION STATUS

_____ ______ ______ ______

BCG DPT1 DPT2 DPT3

_______ _______ ______ ______

________

OPV 0 OPV 1 OPV 2 OPV

3 Measles

Circle immunizations needed today. Return for next immunization

on:

(Date)

•Do you breastfeed your child? Yes____ No ____

IfYes, how many times in 24 hours? ___ times.

Do you breastfeed during the night? Yes___ No___

•Does the child take any other food or fluids? Yes___ No ___

IfYes, what food or fluids?

____________________________________________________

____________________________________________________

How many times per day? ___ times.

What do you use to feed the child? _____________________

If very low weght for age: How large are servings?

_________________________________________________

Does the child receive how own serving? ________________

Who feeds the child and how? ________________________

•During the illness, has the child's feeding changed?

Yes ____ No ____

If Yes, how?

FEEDING PROBLEMS

ASSESS CHILD'S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years old

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TREAT

Return for follow-up on ______________


Give any immunization/s needed today.

Feeding Advice

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Steps To Refer Young Infant /Child

To The Hospital

Explain the mother the need for referral, and get her agreement to take the child.

Calm the mother’s fears.

Write a referral note for the mother to take with her to hospital and give it to doctor.

Give the mother any supplies and instructions needed to care for child on the way to hospital.

The Referral Note Should Include:

Name and age of the child;

Date and time of referral;

Description of the child's problems;

Reason for referral (symptoms and

signs leading to severe

classification);

Treatment that has been given;

Any other information that the

referral health facility needs to know

in order to care for the child, such as

earlier treatment of the illness or any

immunizations needed.

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IMNCI: What Does It Offer?

• Assessment & classification of all children presenting to the

physician

• Initiating treatment for all children

– Counseling

– Initiate Drug treatment

– Pre-referral treatment and referral advice for serious conditions

– Management where referral is not possible

65

IMNCI: What it does not offer?

• Management of serious sick child:

severe pneumonia, severe febrile illness, severe

malnutrition, severe persistent

diarrhoea, sick young infant with sepsis Severe Jaundice

• Care at Birth for all newborns

• Management of Birth asphyxia

• Emergency Triage & treatment(ETAT)

66

F-IMNCI

• F- IMNCI is an integration of the existing IMNCI package and the Facility

Based Care package in to one.

• From November 2009 IMNCI has been re -baptized as F-IMNCI, (F -Facility)

with added component of:

1. Asphyxia Management and

2. Care of Sick new born at facility level, besides all other components

included under IMNCI

• Majority of the health facilities (24x7 PHCs, FRUs, CHCs and District

hospitals) do not have trained paediatricians to provide specialized care to the

referred sick newborns and children, the F-IMNCI training will therefore help in

skill building of the medical officers and staff nurses posted in these health

facilities to provide this care.67

Components of F-IMNCI

• Skill based training

• Improvements to the health system : Logistics/Manpower/ Referral mechanisms

• Improvement of Family and Community Practices

68

Core competenciesIMNCI Facility based care

1 Understand the IMNCI process and

rationale and know how to use the

IMNCI chart

Care at birth

2 Communicate with care-taker ETAT (Emergency Triage and

Treatment)

3 Danger signs in children and

severe signs in newborns and

young infants

Using essential equipment

4 Not many essential procedures Essential Procedures

5 Malnutrition and anaemia Manage referrals

6 Immunization* and vitamin A

supplementation

Severe Acute malnutrition

7 Infant & young child feeding Infant & young child feeding

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C - IMNCI: Community and Household

IMNCI:

• Community IMNCI is basically Component 3 of the IMCI

Package.

• It aims at improving family and community practices by

promoting those Practices with the greatest potential for

improving child survival, growth and development.

• C-IMCI seeks to strengthen the linkage between health services

and communities, to improve selected family and community

practices and to support and strengthen community-based

activities.

70

COMPONENTS:

• The promotion of growth and development of the

child

• Disease prevention

• Appropriate care at home

• Care-seeking outside the home

C - IMNCI: cont.…

71

IMNCI Plus

New born and child health

CARe at BIRTh

IMmUNIZAT

ion

Home and community level

Preventive, Promotive careManagement of

mild illness

Facility careOut patient

careInpatient care

IMNCI

Health system strengthening

BCC & community participation72

Training - Child health

TRAINING STATES DISTRICTS NO.TRAINED

IMNCI 28 433 490000

PRE SERVICE IMNCI

8 STATES-79MEDICAL COLLEGES

4000

73

Implementation Of IMNCI In Uttar

Pradesh

• Uttar Pradesh runs a Comprehensive Child Survival Project(CCSP) where the

IMNCI training module has been expanded to include birth preparedness and

essential care at birth.

• IMR =53(2013) as compared to 57(2011)

• NMR=42(2013) as compared to 47(2011)

• U5MR=90(2013) as compared to 92(2011)

• MMR= 359(2012).

• Involvement of CCSP has really brought down the mortality rates, still the

expansion is required to meet the target.

74

Components of CCSP

four components:

1. IMNCI

2. ANC(ante-natal care)

3. HBNBC(home based new born care)

4. BCC(behavior change communication)

75

References1. Integrated management of neonatal and childhood illness. Modules 1 to 9. Ministry

of health & Family welfare, Government of India, New Delhi. 2009.

2. Student’s handbook for IMNCI. Ministry of health & Family welfare, Government

of India, New Delhi. 2007.

3. Facility based newborn care operational guide. Ministry of health & Family

welfare, Government of India, New Delhi. 2011.

4. Home based newborn care operational guidelines. Ministry of health & Family

welfare, Government of India, New Delhi. 2011.

5. Park K . Textbook of Preventive and Social Medicine. 21st ed. Jabalpur: Bhanot;

2009. p. 414,530,550.

6. Current statistical data on IMR and U5MR from www.worldbank.org (data 2012-

13) accessed on 20-12-2013 at 2:30 am.

7. Ingle GK, Malhotra C. Integrated management of neonatal and childhood illness:

An overview. IJCM 2007 Apr;32(2):108-110.

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integrated management of neonatal and childhood illness(IMNCI)

Health & Medicine