Integrated
Management of
Childhood Illness
Integrated Management of Childhood Illness
WHO Regional Office for the Western Pacific/ Child Health
Causes of 10.5 million deaths among children
< 5 in developing countries, 1999
Pneumonia
19%
One in
every two
child deaths
in perinatal
developing 20% Malnutrition
countries
Diarrhoea
are due to 54%
just five Others 28%
15%
infectious
diseases
and
malnutrition Measles
8%
HIV/AIDS Malaria
3% 7%
Source: EIP/WHO, 1999 data
Important Elements
for Improving Child Health
• Improve case management of sick children
• Improve nutrition
• Ensure immunization
• Prevent injuries
• Prevent other diseases
• Improve psychosocial support and stimulation
Too many different pieces…
Appropriate
Case Care seeking Anemia
management
Home
Nutrition care
HIV/AIDS
Drug
Use
New born
Malaria care
Child Follow-up
rights
Health Safe and
system Mothers Supportive
Communication
health Environment
IMCI brings them all together
IMPROVEMENT OF HEALTH SYSTEM
IMPROVEMENT OF CASE MANAGEMENT
FAMILY AND COMMUNITY PRACTICES
CHILD RIGHTS
IMCI brings it all together
Improving health Strengthening
workers’ skills health system
Improving family
and community
practices
At the start of a sick child
(2 months to 5 years) consultation
• Ask the mother what the child’s
problems are.
• Determine if this is an initial or follow-
up visit for this problem.
IMCI Approach
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
Check for general danger signs
Ask:
• Not able to drink or breastfeed,
• Vomits everything,
• Convulsions, or
Look:
• Abnormally sleepy or difficult
to awaken
Need to Refer
(except in severe dehydration)
Ask about the main symptoms
• Cough or difficulty in breathing
• Diarrhea
• Fever
• Ear problem
Cough or difficulty in breathing
Ask:
• For how long?
Look:
• Count RR
• Chest indrawing The child
must be calm.
• Stridor
Any general danger sign or
Chest indrawing or
Stridor
SEVERE PNEUMONIA OR
VERY SEVERE DISEASE
1st dose of antibiotic
Vitamin A
Breastfeeding/sugar water
URGENT REFERRAL
Fast breathing
2 – 12 months old: ⋝ 50/minute
1 year or older: ⋝ 40/minute
PNEUMONIA
Antibiotic for 5 days
Relieve cough with safe remedy
Advise mother on danger signs
Follow up in 2 days
No signs of pneumonia
or a very severe disease
NO PNEUMONIA: COUGH OR COLD
If cough ⋝ 30 days
refer to hospital for assessment
Relieve cough with safe remedy
Advise mother on danger signs
Follow up in 5 days if no improvement
Diarrhea: Classify
For dehydration
Persistent diarrhea
Blood in the stool
Classify for dehydration
2 or more of the following:
Abnormally sleepy/difficult to wake
Sunken eyes
Not able to feed/drinking poorly
Skin pinch goes back very slowly
SEVERE DEHYDRATION Plan C
Plan C: To treat dehydration quickly
IV fluid: LRS 100 ml/kg body weight
(in 6 hrs for infants; 3 hrs for children)
NO
IV treatment within 30 minutes
NO
Oresol/NGT
Plan C: To treat dehydration quickly
Oresol/NGT
NO
Oresol p.o.
NO
URGENT REFERRAL
Classify for dehydration
2 of the following:
Restless, irritable
Sunken eyes
Skin pinch goes back slowly
SOME DEHYDRATION Plan B
Plan B: Treat some dehydration with ORS
Determine the amount (in ml) of Oresol
to be given in 4 hours
= weight of the child (in kg) X 75, or
if weight is unknown, use this chart.
Age 12<mos-2
4 mosyrs 4-12
2-5 yrs
mos
Amount 700-900
200-400 900-1400
400-700
Plan B: Treat some dehydration with ORS
Show the mother how to give Oresol to
the child: frequent sips from a cup
If the child vomits, wait for 10 minutes.
Then continue, but more slowly.
Continue breastfeeding if the child
wants to breastfeed.
If the child develops puffy eyelids, stop
ORS.
Plan B: Treat some dehydration with ORS
After 4 hours:
Reassess the child & classify for
dehydration.
Select appropriate plan.
Begin feeding the child in the health
center.
Classify for dehydration
Not enough signs to classify as
SEVERE DEHYDRATION or
SOME DEHYDRATION
NO DEHYDRATION Plan A
Plan A: Treat diarrhea at home
Give extra fluid.
Up to 2 yrs 50 – 100 ml after each LBM
2 -4 yrs 100 – 200 ml after each LBM
Continue feeding.
Know when to return.
Persistent diarrhea: 14 days or more
+ Dehydration=severe persistent diarrhea
• Treat dehydration
• Give Vitamin A
• Refer to hospital
Persistent diarrhea: 14 days or more
No dehydration=persistent diarrhea
• Advise regarding feeding
• Give Vitamin A
• Follow up in 5 days
Blood in the stool = dysentery
• Oral antibiotic for shigella for
5 days
• Follow up in 2 days
Fever: (history/temperature 37.5°C or above)
Malaria risk?
Measles now or w/in last 3 mos
Dengue risk?
Fever: Ask about malaria risk
• Residing in endemic area?
OR:
• Travel & overnight
stay in endemic area, or w/in past
• Blood transfusion 6 mos
Malaria risk +
• Blood smear
• Ask: Duration of fever?
Present everyday?
• Look: Stiff neck
Runny nose
Other signs of measles
Malaria risk +
any general danger sign or stiff neck
Very severe febrile disease/malaria
• Quinine (under med. supervision)
• 1st dose of antibiotic, Paracetamol
• Urgent referral
Malaria risk +, blood smear +
No runny nose, no measles
Malaria
• Oral antimalarial
• Paracetamol
• Follow up in 2 days
• > 7 days fever hospital for
assessment
No malaria risk
Any general danger sign or stiff neck
Very severe febrile disease
• 1st dose of antibiotic, Paracetamol
• Urgent referral
Measles now or w/in last 3 mos
Clouding of cornea or
Deep or extensive mouth ulcers
Severe complicated measles
• 1st dose of antibiotic, Vitamin A
• Urgent referral
Measles now or w/in last 3 mos
Pus draining from the eye or
Mouth ulcers
Measles with eye or
Mouth complications
• Vitamin A
• Tetracycline eye ointment
• Gentian violet
• Follow up in 2 days
Measles now or w/in last 3 mos
No other signs
Measles
• Vitamin A
If there is Dengue risk
Bleeding gums, nose, in vomitus or
stools
Black vomitus or stools
Persistent abdominal pain
Persistent vomiting
Skin petechiae
Slow capillary refill
No signs, but fever > 3 days
Tourniquet test
Any of the danger signs
or + tourniquet test
Severe Dengue hemorrhagic fever
• If skin petechiae, persistent abdominal
pain or vomiting, or + tourniquet test
only signs, give ORS
• Any other signs of bleeding Plan C
• Urgent referral
• Do not give aspirin
Ear problem:
tender swelling behind ear
Mastoiditis
• 1st dose of antibiotic
• Paracetamol for pain
• Urgent referral
Ear discharge < 14 days or
Ear pain
Acute ear infection
• Antibiotic for 5 days
• Paracetamol for pain
• Wicking
• Follow up in 5 days
Ear discharge for 14 days or more
Chronic ear infection
• Wicking
• Follow up in 5 days
Visible severe wasting or
Edema on both feet or
Severe palmar pallor
Severe malnutrition or
severe anemia
• Vitamin A
• Urgent referral
Some palmar pallor or
Very low weight for age
Anemia or very low weight for age
• Assess for feeding problem
• Pallor: iron & Albendazole
• Wt for age very low: Vitamin A