The INTEGRATED

MANAGEMENT OF
CHILDHOOD ILLNESS
Suzanne Y. Cañete
What is IMCI?

A strategy for reducing

mortality and morbidity
associated with major causes
of childhood illness

A joint WHO/UNICEF initiative

since 1992
 DOH Essential Package of Child Survival Interventions

 Skilled attendance during

pregnancy, childbirth and the
immediate postpartum
 Care of the newborn
 Breastfeeding and complementary
feeding
 Micronutrient supplementation
 Immunization of children and
mothers
 Integrated management of sick
children
 Use of insecticide treated bed nets
(in malarious areas)
What is IMCI?

According to the World Bank,

the IMCI likely to have the
greatest impact in reducing the
global burden of disease
The INTEGRATED
MANAGEMENT OF
CHILDHOOD ILLNESS
Designed to teach integrated
management of sick infants
and children to first level HWs
in primary care settings that
have NO laboratory support
and only a limited number of
essential drugs
The INTEGRATED
MANAGEMENT OF
CHILDHOOD ILLNESS

Action-oriented
CLASSIFICATIONS, rather
than EXACT DIAGNOSES, are
used
The INTEGRATED
MANAGEMENT OF
CHILDHOOD ILLNESS

Using few CLINICAL SIGNS as

possible which health workers of
diverse background can be
trained to recognize
The INTEGRATED
MANAGEMENT OF
CHILDHOOD ILLNESS

Case Management Process

 IMCI Case Management

Classification
Focused Assessment
Need to Refer
Danger signs
Main Symptoms
Nutritional status Specific treatment
Immunization status
Other problems Home
management

Counsel & Follow-up Treatment

Counsel caretakers Identify treatment

Follow-up Treat
 The INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS

Assess and Classify the Sick Child

age 2 months up to 5 years

Management of the Sick Young

Infant Age 1 week up to 2 months
The INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS

Classifying the Illness

- Most have three rows
- Each row is colored either
pink, yellow, or green
The INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS

Classifying the Illness

PINK
- needs urgent attention and
referral or admission for
inpatient care
- a severe classification
The INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS

Classifying the Illness

YELLOW
- child needs an appropriate
antibiotic, an oral antimalarial,
or other treatment
- includes home teaching to
mother
The INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS

Classifying the Illness

GREEN
- child does not need specific
medical treatment
- includes home teaching to
mother
The INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS

Classifying the Illness

- Always start with the top row
- A child receives only one
classification
- Always select the more serious
classification
 Classifying the Illness

Cough or difficult breathing

SIGNS CLASSIFY AS TREATMENT

Any general danger sign or SEVERE PNEUMONIA Give first dose of an appropriate antibiotic
Chest Indrawing or Give Vitamin A
OR VERY SEVERE Treat the child to prevent low blood sugar
Stridor in calm child DISEASE Refer URGENTLY to hospital

Fast breathing PNEUMONIA Give an appropriate antibiotic for 5 days

Soothe the throat and relieve the cough with
a safe remedy
Advise the mother when to return
immediately
Follow- up in two days
No signs of pneumonia or NO PNEUMONIA: If coughing more than 30 days, refer for
very severe disease assessment
COUGH OR COLDS Soothe the throat and relieve the cough with
a safe remedy
Advise mother when to return immediately
Follow-up in 5 days if not improving
The INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS

How to select the appropriate case

***Decide which age group the

child is in
 Assess And
Classify The Sick
Child Aged 2
Months Up To 5
Years
 Ask the mother what the
child’s problems are
• Determine child’s age
• Determine if this is an initial or
follow-up visit for this problem
 Check for General Danger
Signs
• Ask
– Is the child not able to drink or
breastfeed?
– Does the child vomit everything?
– Has the child had convulsions?
• Look
– Child is abnormally sleepy or difficult to
awaken?
 Check for General Danger
Signs
• If the child has a general danger
sign, complete the rest of the
assessment IMMEDIATELY.
• There must be no delay in the
treatment
 Ask about Main Symptoms
• Does the child have cough or difficult
breathing?
• Does the child have diarrhea?
• Does the child have fever?
• Does the child have an ear problem?
Assess for Malnutrition and
Anemia
• Visible and severe wasting
– Thin, no fat
– Outline of ribs easily seen
– Hips small when compared to chest and
abdomen
– Fat of the buttocks is missing
– Abdomen large or distended
Visible, severe wasting
Visible, severe wasting
 Assess for Malnutrition and
Anemia
• Look for edema of both feet
 Assess for Malnutrition and
Anemia

• Look for palmar pallor

- some palmar pallor (pale)
- severe palmar pallor (very pale
that the palm looks white)
Palmar pallor
Palmar pallor
Palmar pallor
• Determine weight for age
 Classify Nutritional Status
SIGNS
Visible severe wasting or
Edema of both feet or
Severe palmar pallor
Some palmar pallor or
Very low weight for age
Not very low weight for age
and no other signs of
malnutrition
CLASSIFY AS TREATMENT
SEVERE Give Vitamin A
MALNUTRITION Refer URGENTLY to hospital
OR SEVERE
ANEMIA
ANEMIA OR Assess the child’s feeding and counsel the
mother on feeding according to the FOOD box
VERY LOW on the COUNSEL THE MOTHER chart.
WEIGHT -If feeding problem, follow- up in 5 days.
If some pallor:
-Give iron.
-Give Mebendazole if child is 2 years or older
and has not had a dose in the previous 6
months.
-Follow- up in 14 days.
If very low weight for age:
-Give Vitamin A.
-Follow-up in 30 days.
Advise mother when to return immediately
NO ANEMIA AND If the child is less than 2 years old, assess
the child’s feeding and counsel the mother
NOT VERY LOW on feeding according to the FOOD box on
WEIGHT the COUNSEL THE MOTHER chart,
If feeding problem, follow- up in 5 days,
Advise mother when to return
immediately.
 Check the Child’s
Immunization Status
Birth BCG, Hep B-1

6 weeks DPT-1, OPV-1, Hep B-2

10 weeks DPT-2, OPV-2

14 weeks DPT-3, OPV-3, Hep B-3

9 months Measles
 Check the Child’s
Immunization Status

Three contraindications:
-BCG to a child known to have AIDS
-DPT 2 or 3 to a child who has had convulsions
or shock within 3 days of most recent dose
-DPT to a child with recurrent convulsions or
another active neurological disease of the
central nervous system
 Check the Child’s
Immunization Status

There are no contraindications to

immunization of a sick child if the child
is well enough to go home.
Check the Child’s Vitamin A
Status

VITAMIN A SUPPLEMENTATION
SCHEDULE:
First dose at 6 months or above
Subsequent doses every 6 months.
Check the Child’s Vitamin A
Status

Initial dose:
100,000 IU of Vitamin A

Subsequent doses:
200,000 IU of Vitamin A every six months
up to the age of 59 months
 Assess child’s feeding
(has ANEMIA OR VERY LOW WEIGHT OR < 2 YEARS OLD)

• Ask
– Do you breastfeed your child?
• How many times during the day?
• Do you also breastfeed during the night?
 Assess child’s feeding
• Ask
– Does the child take any other food or
fluids?
• What foods or fluids?
• How many times during the day?
• What do you use to feed the child?
• If low weight for age: How large are the
servings?
• Does the child receive his own serving?
Who feeds the child and how?
 Assess child’s feeding

• Ask
– During this illness, has the child’s
feeding changed? If yes, how?
Assess care for development
• Ask questions about how mother
cares for her child. Compare the
mother’s answers to the
Recommendations for Care and
Development for child’s age
Assess care for development
• Ask
– How do you play with your child?
– How do you communicate with your
child?
Assess other problems.
 IDENTIFY
TREATMENT
 Outline
• Determine if urgent referral is needed
• Identify treatments needed
• For patients who need urgent referral:
– Identify the urgent pre-referral treatments
– Explain the need for referral to the mother
– Writing the referral note
 Flow chart of Identifying
Treatment
2.0 Identify treatment for patient who
do not need urgent referral

No

1.0
Determine
if urgent
referral is
needed

3.0 Identify 4.0 Give pre- 5.0 Refer the

Yes urgent pre- referral child
referral treatment treatment
needed
DETERMINE IF URGENT
REFERRAL IS NEEDED
 DETERMINE IF URGENT
REFERRAL IS NEEDED
Referral for Severe Classifications
• Severe Pneumonia or very severe disease
• Severe Dehydration
• Severe Persistent Diarrhea
• Very Severe Febrile Disease/ Malaria
• Very Severe Febrile Disease
 DETERMINE IF URGENT
REFERRAL IS NEEDED
Referral for Severe Classifications
• Severe Complicated Measles
• Severe Dengue Hemorrhagic Fever
• Mastoiditis
• Severe Malnutrition or Severe Anemia
 Exceptions
• Severe Persistent Diarrhea
• Severe Dehydration

If the child’s only classification is SEVERE

DEHYDRATION, use Plan C to decide whether to
refer the child

If the child has another classification in addition to

Severe Dehydration, refer the child
 Referral for General
Danger Signs

• Make sure child with any general danger

sign is referred after first dose of an
appropriate antibiotic and other urgent
treatments
 Remember

(-) general danger signs, severe

classifications, or other severe
problems

MEANS

(-) urgent referral to a hospital

 IDENTIFY
TREATMENTS FOR
PATIENTS WHO DO
NOT NEED URGENT
REFERRAL
 Identify Treatment
• List only the treatments that apply to the
specific child being treated
• Include items for follow-up
• If several different times are specified for
follow-up, you will look for the earliest
definite time
 CHECKPOINT!!!

1 follow up in 2 days
2 follow up in 5 days
5 follow up in 5 days if not improving
3 follow up in 30 days
4 follow up in 2 days if fever persists
 IDENTIFY and GIVE
URGENT PRE-
REFERRAL TREATMENT
NEEDED
 Pre-referral Treatment
• Give an appropriate antibiotic
• Give Quinine for SEVERE MALARIA
• Give Vitamin A
• Treat the child to prevent low blood
sugar
 Pre-referral Treatment
• Start IV fluids according to Plan C for
child with severe dengue hemorrhagic
fever with bleeding or cold clammy skin
or capillary refill more than 3 seconds
 Pre-referral Treatment
• Give ORS according to Plan B for a child
with SEVERE DENGUE HEMORRHAGIC
FEVER severe with only petechiae or a
positive tourniquet test or abdominal
pain or vomiting but without cold clammy
skin and with a normal capillary refill
time
 Pre-referral Treatment
• Give an oral antimalarial
• Give paracetamol for high fever (38.5°C
or above) or pain from MASTOIDITIS
• Apply Tetracycline eye ointment if
clouding of the cornea and pus draining
from eye
• Provide ORS solution so that the mother
can give frequent sips on the way to the
hospital
REFER THE CHILD
 Refer the child
• Explain to the mother the need for the
referral, and get her to agree

• Calm the mother’s fears and help her

resolve any problems
TREAT THE
CHILD
 Outline
I. Select the appropriate oral drug
and determine dose and schedule
II. Use good communication skills
III. Teach the mother to give oral drugs
at home
IV. Local Treatments
V. Health Center Treatments
COUNSEL THE
MOTHER
 OUTLINE
• FEEDING RECOMMENDATIONS
• CARE FOR DEVELOPMENT
• WHEN TO RETURN
• MOTHER’S OWN HEALTH
FEEDING RECOMMENDATIONS
• Exclusive breastfeeding
• Complementary foods
 Sick child:
FEEDING PROBLEMS
Difficulty breastfeeding
Using of feeding bottle
Lack of active feeding
Not feeding well during illness
Not giving protein source of food
in lugaw or rice
Improper handling and use of
breastmilk substitute
 Sick child:
FEEDING PROBLEMS
Teaching Correct Positioning and Attachment for
Breastfeeding

SIGNS OF GOOD ATTACHMENT:

chin touching breast
mouth wide open
lower lip turned outward
more areola visible above than below
the mouth
Good attachment?

A B
Good attachment?

A B
 Sick child:
FEEDING PROBLEMS
Poor ATTACHMENT can be influenced by
proper POSITIONING of the young
infant during breastfeeding.
SIGNS OF GOOD POSITIONING:
Infant’s neck is straight or bent
slightly back
Infant’s body is turned towards the
mother
Infant’s body is close to the mother
Infant’s whole body is supported
Good position?

A B
Good position?

A B
 CARE FOR DEVELOPMENT

Common Problems:
• Mother cannot breastfeed
• Mother does not know what her
child does to play or
communicate
• Mother feels she does not have
enough time to provide care for
development
 Common Problems
Mother has no toys for her child
to play with
Child is not responding, or seems
“slow”
Child is being raised by someone
other than the mother
 When to return
Follow-up visit in a specific
number of days
Immediately, if signs appear that
suggest the illness is worsening
For the child’s next immunization
 When to return
immediately
• Any sick child:
– Not able to drink or breastfeed
– becomes sicker
– Develops a fever
 When to return
immediately
• If child has NO PNEUMONIA: COUGH OR
COLD, also return if:
– Fast breathing
– Difficult breathing
 When to return
immediately
• If child has diarrhea, also return if:
– Blood in the stool
– Drinking poorly
 When to return
immediately
• If child has FEVER: DENGUE
HEMORRHAGIC FEVER UNLIKELY, also
return if:
– Any sign of bleeding
– Persistent abdominal pain
– Persistent vomiting
– Skin rashes
– Skin petechiae
Give Follow
up Care
Thank you!