THE IMCI STRATEGY  Improves equity

Integrated Management of Childhood Illness The IMCI Case Management Process

 An integrated approach to child health that 1.Assess
focuses on the well-being of the whole child. 2.Classify
 Aims to reduce death, illness & disability, and to 3.Identify Treatment
promote growth and development among under 4.Treat
under 5 children. 5.Counsel the Mother
 It combines improved management of childhood 6.Follow-Up
illness with aspects of Nutrition, VAC
supplementation, deworming, immunization, and
other factors influencing child and maternal
health. Age groups
 A strategy for reducing mortality and morbidity  Sick Child Aged 2 months up to 5 years
associated with major causes of childhood illness.  Young Infants Aged Up to 2 months
 A joint WHO/UNICEF initiative since 1992
 Currently focused on first level health facilities The IMCI Case Management Process
 Comes as a generic guidelines for management
which have been adapted to each country ASSESS AND CLASSIFY

Diseases comprising 70% of deaths among Check for GENERAL DANGER SIGNS
under 5 children  not able to drink or breastfeed
 Pneumonia  vomits everything
 Diarrhea  convulsions
 Dengue hemorrhagic fever  abnormally sleepy or difficult to awaken
 Malaria
Not able to drink or breastfeed
 Measles
 Not able to suck or swallow when offered a drink
 Malnutrition
or breast milk because he/she is too weak or
cannot swallow
Objectives of IMCI
 Ask: Is the child able to take fluid into his/her
 To reduce significantly global mortality and
mouth and swallow it?
morbidity associated with the major causes of
Vomits everything
disease in children.
 Not able to hold anything down
 To contribute to healthy growth and development
of children.  What goes down comes back up
 Assess for “General Danger Signs”  Check: offer the child fluid – water or expressed
breast milk
 Routinely assess for major symptoms.
Convulsion
 Use limited number of carefully selected clinical
 Arms and legs stiffen because the muscles are
signs.
contracting
 Address most, if not all of the major reasons a
 The child may lose consciousness or not able to
child is brought to the clinic.
respond to spoken directions or handling, even if
 Use a limited number of essential drugs and
the eyes are open
encourage participation of caretakers in the
 May be due to fever or associated with
treatment.
meningitis, cerebral malaria or other life
 Counseling of caretakers.
threatening conditions
Abnormally sleepy or difficult to awaken
Components of IMCI
 Drowsy and does not take notice of his/her
 Improving case management skills of health
surroundings
workers.
 Does not respond normally to sounds or
o Standard guidelines
movement
o Training (pre-service and in-service)
 Stares blankly and appear not to notice what is
o Follow-up after training
going on
 Improving the health system to deliver IMCI:
 Cannot be wakened. Does not respond when
o Essential drug supply and management
touched, shaken, or spoken to
o Organization of work in health facilities
o Management and supervision Assess & Classify THE 4 MAIN SYMPTOMS
 Improving family and community practices  Cough or difficult breathing
 Diarrhea
Benefits of IMCI
 Fever
 Addresses major child health problems
 Ear problem
 Responds to demand
 Promotes preventive as well as curative care Assess and classify cough or difficult breathing
 Cost-effective  How long?
 Promotes cost saving
  Count the breaths in one minute. Decide if fast Two of the following signs: Severe
breathing is present Abnormally sleepy or Dehydration
 Look for chest indrawing difficult to awaken
 Look and listen for stridor Sunken eyes
 Look and listen for wheeze Not able to drink or drinking
o If wheezing and either fast breathing or poorly
chest indrawing: Skin pinch goes back very
- Give a trial rapid acting inhaled slowly
bronchodilator for up to three times 15- Two of the following signs: Some Dehydration
20 minutes apart. Count the breaths and Restless, irritable
look for chest indrawing again, then Sunken eyes
classify. Drinks eagerly, thirsty
- 0.5 ml salbutamol diluted in 2.0 ml of Skin pinch goes back slowly
sterile water per dose nebulization should Not enough signs to classify No Dehydration
be used. as some or severe
 Assess and Classify Cough or Difficult breathing dehydration
If child is: Fast Breathing is:
2 months up to 12 50 breaths per minute or If diarrhea is 14 days or more
months more Dehydration present. Severe persistent
12 months up to 5 40 breaths per minute or diarrhea
years more No Dehydration. Persistent Diarrhea
Chest Indrawing – the lower chest wall goes IN as
If there is blood in stool
the child breaths IN
Blood in the stool Dysentery
Stridor – a harsh noise as the child breaths IN
Wheeze – soft musical noise made when the child
breaths OUT Assess Fever
 Decide malaria risk
 If malaria risk, obtain a blood smear
 For how long?
 If more than 7 days, has fever been present
every day?
 Has the child had measles within the last 3
months
Classify the illness  Look or feel for stiff neck.
Urgent pre-referral treatment and referral  Look for runny nose.
Specific medical treatment and advice  Look for signs of measles.
Simple advice on home management  If child has measles now or within the last 3
months:
Classify cough or difficult breathing o Look for mouth ulcers
Any general danger sign Severe pneumonia o Look for pus draining from the eyes.
Chest indrawing or Very Severe o Look for clouding of the cornea
Stridor in calm child Disease
Fast breathing Pneumonia Generalized Rash of Measles
(If wheezing go directly to
treat wheezing) Measles Complications:
No signs of pneumonia or No Pneumonia:  Mouth Ulcer
very severe disease Cough or Cold  Pus Draining from Eye
(If wheezing go directly to  Clouding of the Cornea
treat wheezing) Classify fever (Malaria Risk)
Any general danger sign Very Severe Febrile
Assess diarrhea Stiff neck Disease/Malaria
 For how long? Blood smear (+) Malaria
 Is there blood in the stool? If no blood smear: no runny
 Look at the child’s gen. condition. nose and no measles and
 Look for sunken eyes. no other causes of fever
 Offer the child fluid – drinking Blood smear (-) or runny Fever: Malaria
normally/poorly/eagerly? Not able to drink? nose or measles or other Unlikely
 Pinch the skin of the abdomen. causes of fever
o Look for sunken eyes
o Skin Pinch that goes back Very Slowly Classify fever (No Malaria Risk)
Any general danger sign Very Severe Febrile
Classify diarrhea for dehydration Stiff neck Disease
No signs of very severe Fever: No Malaria
febrile disease
Classify Measles
Clouding of the cornea Severe
Deep or extensive mouth Complicated
ulcers Measles Check for malnutrition and anemia
Any general danger sign For all Children:
Pus draining from the eye, Measles with Eye or  Determine weight for age.
or Mouth ulcers Mouth  Look for edema of both feet.
Complications  Look for visible severe wasting.
Measles now or within the Measles For children aged 6 months or more, determine if
last 3 months MUAC is less than 115 mm

Assess/Classify Dengue Hemorrhagic Fever Signs of Severe Malnutrition

 Bleeding from nose or gums  Edema of Both Feet
 Bleeding in stools/vomitus  Visible Severe Wasting
 Black stools/vomitus
 Skin petechiae Classify Nutritional Status:
 Cold and clammy extremities If age up to 6 months SEVERE
 Capillary refill more than 3 seconds - and visible severe MALNUTRITION
 Persistent abdominal pain wasting
- and edema of both feet
 Persistent vomiting
 Tourniquet test positive If age 6 months and above
and:
Assess DHF - MUAC less than 115mm
 Skin petechiae – dark red spots or patches in the or edema of both feet or
skin. When skin is streached, they do not visible severe wasting
disappear Very low weight for age VERY LOWWEIGHT
 Persistent abdominal pain – continuous, without Not very low weight for age NOT VERY LOW
relief and no other signs of WEIGHT
 Persistent vomiting – not associated with food malnutrition
intake
Check for Anemia
 Positive tourniquet test – 20 or more petechiae in LOOK AND FEEL:
one square inch
 Look for palmar pallor. Is it
Assess/Classify Dengue Hemorrhagic Fever  Severe palmar pallor?
 Some palmar pallor
 Any one sign present: Severe Dengue
Hemorrhagic Fever Check for Signs of Anemia
 No sign present - Fever: Dengue Hemorrhagic  No palmar pallor
Fever Unlikely  Some palmar pallor
 Severe palmar pallor
Assess Ear Problem
 Is there ear pain? Classify for Anemia:
 Is there ear discharge? For how long? Severe palmar pallor SEVERE ANEMIA
 Look for pus draining from the ear. Some palmar pallor ANEMIA
 Feel for tender swelling behind the ear. No palmar pallor NO ANEMIA

Classify ear problem Check for:

Tender swelling behind the Mastoiditis  Immunization Status
ear  Vitamin A Supplementation Status
Ear Pain Acute Ear Infection  Deworming Status
Pus is seen draining from  Assess for Other Problems
the ear and discharge is
reported for less than 14 Identify Treatment
days  Determine if urgent referral is needed.
Pus is seen draining from Chronic Ear  Identify treatment for patient who do not need
the ear and discharge is Infaction urgent referral.
reported for 14 days or  For patients who need urgent referral, identify
more urgent pre-referral treatment.
No ear pain No Ear Infection  Give pre-referral treatment.
No pus seen draining from  Refer the child with a referral note.
the ear
Acute respiratory infection
First-line/second line antibiotic for non-severe 3.Continue feeding
pneumonia 4.When to Return
PREVIOUS UPDATED
First line Cotrimaxazole Amoxicillin Diarrheal diseases
Second Amoxicillin Cotrimaxazole Use or oral osmolarity oral rehydration salt
line Technical basis:
 Efficacy of ORS solution for tx of acute non-
Duration of antibiotic treatment from 5 days to 3 cholera in children is improved by reducing
days its sodium concentration to 75 mEq/l, its
Frequency of administration of antibiotics from 3x to glucose concentration to 75 mmol/l, and its
2x a day total osmolarity to 245mOsm/l.
 The need for unscheduled supplemental IV is
Management for non-severe pneumonia therefore: reduced by 33%, stool output is reduced by
First line - Oral amoxicillin to be given in 25mg/kg about 20% and the incidence of vomiting by
dose twice daily in children 2-59 months of age for 3 about 30%.
days
Second line - Oral Cotrimoxazole to be given 2x daily Composition
for 3 days mmol/liter
New Old
Sodium 75 90
Technical basis: Chloride 65 80
 3 days treatment is equally effective as the 5 day Glucose, 75 111
treatment anhydrous
 Reduces cost of treatment Potassium 20 20
 Improves compliance Citrate 10 10
 Reduces antimicrobial resistance in the Total 245 311
community Osmolarity
 Use of oral Amoxicillin vs injectable penicillin in
children with severe pneumonia Benefits of Zinc Supplementation
o Where referral is difficult and injection is not  Reduces the severity of diarrhea
available, oral Amoxicillin in 45 mg/kg/dose  Shortens the duration of diarrhea
2x daily should be given to children with  Lowers the number of diarrhea episodes –
severe pneumonia for 5 days protects the child from diarrhea for the next 2 – 3
Technical basis: Clinical outcome with months.
oral amoxicillin was comparable to injectable
penicillin in hospitalized children with severe
pneumonia
 Gentamicin plus ampicillin vs chloramphenicol for
very severe pneumonia Treatment Plan B for Some Dehydration
o Injectable ampicillin plus injectable Give recommended amount of Reformulated ORS:
gentamicin is a better choice than injectable AGE Up to 4 months 12 2 years
o chloramphenicol for very severe pneumonia 4 up to 12 months up to 5
in children 2-59 months of age. month months up to 2 years
o A pre-referral dose of 7.5mg/kg intramuscular s years
injection gentamicin and 50 mg/kg injection WEIGH Less 6 6 to less 10 to 12 to
ampicillin can be used T kg than 10 less less
 Use of oral Amoxicillin vs injectable penicillin in kg than 12 than
children with severe pneumonia kg 20 kg
o Where referral is difficult and injection is not Amou 200- 450-800 800-960 960-
available, oral Amoxicillin in 45 mg/kg/dose nt of 450 1600
2x daily should be given to children with fluid
severe pneumonia for 5 days (ml)
Technical basis: Clinical outcome with over 4
oral amoxicillin was comparable to injectable hours
penicillin in hospitalized children with severe
pneumonia  The approximate amount of ORS required can
also be calculated by multiplying child’s weight
Give Extra Fluid for Diarrhea and Continue Feeding by 75
Treatment Plan A for No Dehydration  If the child wants more ORS, give more
1.Give Extra Fluid:  For infants below 6 months who are not
a.Up to 2 yrs. : 50-100 ml after each loose stool breastfed, also give 100-200 ml clean water
b.2 yrs. Or more: 100-200 ml after each loose during this period.
stool  Give frequent small sips from a cup.
2.Give Zinc Supplements (for 10-14 days):  If child vomits, wait 10 minutes then continue –
a.< 6 mos. : 10 mg/day more slowly
b.6 mos. – 5 yrs: 20 mg/day
  Continue breastfeeding whenever the child wants  Quinolone eardrops may include: ciprofloxacin,
 After 4 hours: Reassess, classify, select norfloxacin, or ofloxacin
appropriate treatment plan; begin feeding the  Follow the “Rule of Three” : 3 drops, tilt head for
child in the clinic. 3 minutes, instill 3 times a day

Treatment Plan C for Severe Dehydration Other Treatments

 Can you give IV fluid? If yes, give IV fluid  Vitamin A for sick children
immediately.  Iron for anemia
 If No: Is IV treatment available nearby (within 30  Paracetamol for high fever (38.5 C or more) and
minutes)? If yes, refer immediately to hospital for for ear pain.
IV treatment.  Mebendazole/Albendazole for deworming.
 If No: Are you trained to use NG tube for  Multivitamins and minerals for Persistent
rehydration? If yes, start rehydration by NG Diarrhea (with at least 2 of Recommended
 If No: Can the child drink? If yes, give ORS by Energy and Nutrient Intake: folate, Vitamin A,
mouth zinc, magnesium, copper)
 If No, refer URGENTLY to hospital for IV or NG  Tetracycline Eye Ointment for eye infection (TID)
treatment.  Quinolone Eardrops & Ear Wicking for ear
discharge (TID).
Diarrheal Diseases  Half-strength Gentian Violet for mouth ulcers
Use of antibiotics in the management of bloody ( BID).
diarrhea (shigella dysentery)  Cough Remedies: breastmilk
 Ciprofloxacin is the most appropriate drug in  tamarind, calamansi, ginger (SKL)
place of nalidixic acid which leads to rapid  Given at Health Center Only:
development of resistance o IM Antibiotic for children being referred who
 Dose: 15 mg/kg body weight 2x a day for 3 days cannot take oral antibiotic :
 Treat the Child: Oral Antibiotics/Antimalarial - Give Gentamicin (7.5 mg/kg) AND
For Cholera: Ampicillin 50 mg/kg
 First Line: Tetracycline
 Second Line: Erythromycin Treat to Prevent Low Blood Sugar
Oral Antimalarial:  Breastfeed more frequently
 First Line: Artemether-Lumefantrine  Give sugar 30-50 ml of milk or sugar water before
 Second Line: Chloroquine, Primaquine, departure (for referral)
Sulfadoxine and Pyrimethamine  To make sugar water: Dissolve 4 level teaspoon
Fever (20 grams) of sugar in 200 ml cup of clean water
Treatment of drug-resistant malaria  If unconscious, give D10 5ml/kg over a few
 In case of parasitological or clinical failure to a minutes or give D50 1ml/kg by slow push.
given drug, refer patient to the next level with
proper documentation (blood smear result incl. Revised Immunization Schedule
parasite count on day7, 14, 21, & 28 Age Vaccine
o Quinine sulfate(300 or 600 mg/tab) Birth BCG, HepB1
o 10 mg/kg/dose every 8 hours for 7 days + 6 weeks DPT1, OPV1, HepB2
Clindamycin 10 mg/kg 2x a day for 3 days 10 weeks DPT2, OPV2
Pre-referral treatment: 14 weeks DPT3, OPV3, HepB3
 Artesunate suppository for uncomplicated P. 9 months Anti – measles
falciparum malaria in infants or young children 12 – 15 MMR
who cannot swallow. months

EAR INFECTIONS Routinely Check for Deworming Status

Chronic ear infection Give Mebendazole/Albendazole
 Chronic ear infection should be treated with otical - Give 500 mg. Mebndazole/400mg Albendazole
quinolone ear drops for at least 2 weeks in as a single dose in the health center if the child
addition to dry ear by wicking is 12 months up to 59 months and has not
Acute ear infection received a dose in the previous 6 months
 Oral amoxicillin is a better choice for the
management of suppurative otitis media in Mebendazole/Albendazole Dose:
countries where antimicrobial resistance to AGE OR WEIGHT Albendaz Mebendaz
cotrimoxazole is high ole 400 ole 500 mg
 Dry the Ear by Wicking and Instill Quinolone mg tab. tab.
Eardrops 12 months up to ½ tablet 1 tablet
 Dry the ear using wick of clean absorbent cloth or 23 months
soft, strong tissue paper. 24 months up to 1 tablet 1 tablet
 Instill quinolone eardrops after wicking 3 times 59 months
daily for 2 weeks
Vitamin A Treatment/Supplementation
 AGE Vitamin A Capsules Diarrhea Blood in stool
100,000 200,000 Drinking poorly
IU IU Fever: DHF Unlikely Any sign of bleeding
6 months up to 12 1 ½ Persistent abdominal pain
months capsule capsule Persistent vomiting
12 months up to 5 1 capsule Skin petechiae/ Skin rash
yrs
Give Follow-Up Care: Persistent Diarrhea
 Counsel the Mother on Infant Feeding  After 5 days:
1.Exclusive breastfeeding up to 6 mos.  Ask: Has the diarrhea stopped?
 Breastfeed as often as the child wants,  How many loose stools is the child having per
day and night at least 8 times in 24 hours day?
 Breastfeed when the child shows signs of
hunger, beginning to fuss, sucking Treatment
fingers, or moving the lips  If diarrhea has not stopped (3 or more/day), do a
 Do not give other foods or fluids full reassessment. Give any treatment needed.
2.Complementary feeding 6 mos. up to 23 mos. Refer to hospital.
 Breastfeed as often as the child wants  If diarrhea has stopped, tell the mother to follow
 Give adequate serving of complementary the feeding recommendation for child’s age.
foods: 3 times per day if breastfed, with
1-2 nutritious snacks as desired from 9- Assess: Age up to 2 months
23 mos. Previous Updated
 Give foods 5 times per day if not Age: 1 week up to 2 Birth up to 2
breastfed with 1 or 2 cups of milk months months
 Give small chewable items to eat with
fingers. Let the child try to feed itself, but Main symptom:
provide help Previous: Possible serious bacterial infection
3.Management of severe malnutrition where referral is Updated: Very severe disease and local bacterial
not possible infection
 Where a child is classified as having
severe malnutrition and referral is not Signs to look for in assessment:
possible, the IMCI guidelines should be Previous: 12 signs
adapted to include management at first- Updated: 7 signs
level facilities Classify: Aged Up to 2 months (Updated)
 modified milk diet is given  Not feeding well, or
4.HIV and Infant Feeding  Convulsions, or
 In areas where HIV is a public health  Fast breathing (60 bpm or more), or
problem all women should be encouraged  Severe chest indrawing, or
to receive HIV testing and counseling  Fever (37.5 C or above), or
 If a mother is HIV-infected and  Low body temp. (less than 35.5 C), or
replacement feeding is acceptable,  Movement only when stimulated or no movement
feasible, affordable, sustainable and safe at all
for her and her infant, avoidance of all
breastfeeding is recommended. Classify, Identify Treatment
Otherwise, exclusive breastfeeding is Red Local • Give an appropriate
recommended during the first months of umbilic Bacteri oral antibiotic.
life us al • Teach the mother to
 The child of HIV-infected mother who is Skin Infectio treat local infections
not breastfed should receive pustule n at home.
complementary foods s • Advise mother how to
 Care for Development – communication and play give home care for
 Increase fluids during illness the young infant.
 When to Return: • Follow-up in 2 days.
o for follow-up
o immediately Checking for jaundice is added in the protocol
o for immunization
Classification: Severe jaundice (pink), Jaundice
When to Return Immediately (yellow), No jaundice (green)
Any sick child Not able to drink or  Any jaundice if age SEVERE
breastfeed less than 24 hrs, or JAUNDICE
Becomes sicker  Yellow palms and
Develops fever soles at any age
No Pneumonia: Fast breathing  Jaundice appearing JAUNDICE
Cough or cold Difficult breathing after 24 hrs of age,
and
  Palms and soles not  Move her infant quickly onto breast, aiming the
yellow infant’s lower lip well below the nipple.
 Look for signs of good attachment and effective
 No Jaundice NO JAUNDICE
suckling. If the attachment or suckling is not
good, try again.
Assess and Classify diarrhea
 For dehydration ( severe, some or no Signs of Good Attachment
dehydration)  Chin touching the breast
 If diarrhea is 14 days or more: Severe Persistent  Mouth wide open.
Diarrhea  Lower lip turned outward.
 If blood in stool: Dysentery  More areola visible above the top lip than below
the lower lip.
Check for feeding Problem or Low Weight
Not well attached to Feeding Advise Mother to Give Home Care for the Young
breast Problem or Low Infant
Not suckling effectively Weight
 Food and Fluid: Breastfeed frequently, as often
Less than 8 feeds in 24
and for as long as the infant wants.
hrs.
 When to Return:
Receives other foods or
o For Follow-up Visit
drinks
Low weight for age o Immediately
Thrush o For Immunization
Not low weight for age No feeding  Make sure the young infant stays warm at all
and no other signs of Problem times.
inadequate feeding
When to Return Immediately
Assess: Age up to 2 months  Breastfeeding or drinking poorly.
 Check for the young infant’s immunization status  Becomes sicker.
 Assess other problems  Develops fever.
 Fast breathing.
Treat the Young Infant  Difficult breathing.
 Give an appropriate oral antibiotic:  Blood in stool.
 First Line: Amoxycillin
 Second Line: Cotrimoxazole ( Not given in infants Follow-Up Care: Oral Thrush
less than 1month of age who are premature or  After 2 days:
jaundiced).  Look for ulcers or white patches in the mouth.
 Injectable Antibiotic (for referred patients unable  Reassess feeding
to take oral antibiotic or for cases where referral  If thrush is worse, or if the infant has problems
is not possible): Ampicillin and Gentamicin with attachment or suckling, refer to hospital.
 If thrush is the same or better, and the infant is
Treat Skin Pustules feeding well, continue half-strength Gentian
 Wash hands. Violet for a total of 5 days.
 Gently wash off pus and crusts with soap and
water. Technical updates adapted in Philippine IMCI
 Dry the area.  Antibiotic treatment of non-severe and severe
 Paint with full-strength Gentian Violet. pneumonia
 Wash hands.  Low osmolarity ORS and antibiotic treatment for
Treat Umbilical Infection bloody diarrhea
 Wash hands.  Treatment of fever/malaria
 Paint with full-strength Gentian Violet.  Treatment of ear infections
 Wash hands.  Infant feeding
 Treatment of helminthiasis
Treat Oral Thrush  Management of sick young infant aged up to 2
 Wash hands. months
 Wash mouth with clean soft cloth wrapped
around the finger and wet with salt water.
 Paint the mouth with half-strength Gentian Violet.
 Wash hands.

Teach Correct Positioning and Attachment for

Breastfeeding
 Show her how to help the infant to attach. She
should:
 Touch her infant’s lips with her nipple.
 Wait until her infant’s mouth opening wide,