Integrated

Management of
Childhood Illness
(IMCI)
AN OVERVIEW
IMCI

WHAT IS IMCI?
 a strategy for reducing mortality and
morbidity associated with major causes of
childhood illness
 A joint WHO/UNICEF initiative since 1992
Essential Package for
Child Survival
 Skilled attendance during
pregnancy, delivery and
immediate postpartum
 Care of the newborn
 Breastfeeding and
complementary feeding
 Micronutrient supplementation
 Immunization of children
and mothers
 Integrated management of
sick children (IMCI)
 Use of insecticide-treated
bed-nets
IMCI
OBJECTIVES

 To reduce SIGNIFICANTLY global

mortality and morbidity assoc. with the
major causes of disease in children
 To contribute to healthy growth and
development of children
MAJOR CAUSES OF DEATH UNDER FIVE,
2002
ARI
Other 18%
25%

Deaths assoc. with Diarrhea 15%

malnutrition
54%

Perinatal
23% Malaria 10%

Measles 5%
HIV/
AIDS
4%
IMCI
THE PROBLEM:
1. The under five population is the most
vulnerable group
2. Child mortality remains
UNACCEPTABLY HIGH
3. Many of these deaths had no medical
attendance or being seen by first –level
health facilities
IMCI
THE PROBLEM
4. First-level facilities:
- undermanned/underpaid
- HW’s are not appropriately TRAINED
- drug supply inadequate/not properly
managed
- inaccessible
- poor laboratory support
 IMCI
THE PROBLEM
5. Family and community profile/ practices
- late “help seeking” behavior
- poor utilization of health facilities
- literacy
- traditional beliefs/traditions
- economic
- large families
- crowded, dense, polluted environment
100 Main symptoms of 45092.5
sick children
%
90 82.5%
80
70
60
50 45%
40
30
20 8.4%
10
0
Cough Diarrhea Fever Ear problems
 IMCI
Frequency of presenting complaints of 450
children (as volunteered by mothers)
Fever
Cough Covered by
Diarrhea IMCI
Ear problems (87 %)
Skin lesions
Abdominal pain
Eye discharge
Not covered by IMCI
Dental problems
(13%)
Neck swelling
Gen. swelling
Anorexia
Rectal prolapse
Headaches
Not recorded

-10 10 30 50 70
Main symptoms of 478 children
VSMMC

70

60

50

40

30

20

10

0
COUGH FEVER DIARRHEA EAR PROBLEM
 FREQUENCY OF 4 MAIN SYMPTOMS IN EACH
PATIENT
VSMMC

62%
ONE SYMPTOM

2 SYMPTOMS 31%

3 SYMPTOMS 4%

4 SYMPTOMS 3%

0 20 40 60
 FACTS ABOUT IMCI

“ The IMCI training was designed to teach

integrated management of sick young
infants and children to first level HW’s in
primary care settings that have NO
laboratory support and only a limited
number of essential drugs.”
“ Action oriented CLASSIFICATIONS ,
rather than EXACT DIAGNOSES, are
used.”
“ A careful balance has been struck
between SENSITIVITY and SPECIFICITY
 “Using FEW CLINICAL SIGNS as
possible which health workers of diverse
background can be trained to recognize”
“ The IMCI guidelines rely on detection of
cases based on SIMPLE CLINICAL
SIGNS, without laboratory tests, and offer
EMPIRIC TX “
IMCI
COMPONENTS
 Improving case management skills of
health workers
a. standard guidelines
b. training (pre- service and in- service)
c. follow-up after training
IMCI
COMPONENTS
 Improving the health system to deliver
IMCI
a. essential drug supply
b. organization of health facilities
c. management of supervision
IMCI
COMPONENTS
 Improving family and community practices
IMCI
CASE MX PROCESS
1. HW assesses the sick child
- IDENTIFY any danger sign present
- ASK about the four(4) main symptoms
cough, diarrhea, fever, and ear problem
- REVIEW nutrition, Vit A ,immunization
IMCI
CASE MX PROCESS
3. HW then identifies SPECIFIC TX
- an INTEGRATED TREATMENT PLAN is
developed
- decides referral (hospital) or home
IMCI
CASE MX PROCESS
4. TREATMENT INSTRUCTIONS are carried out:
referral: pre-referral treatment, convincing
mothers to go to hospital, arranging for transport
home care: continue feeding, fluids, others;
oral drugs, ORS, treat local infections,
signs to come back immediately, when to return
for routine follow-up
5. COUNSELING mothers
6. FF-UP instructions when the child returns to
clinic
TOOLS:

 WALL CHART
 CHART BOOKLET
 RECORDING FORMS
CONTENTS :

 ASSESS
 CLASSIFY
 IDENTIFY TREATMENT
HOW TO SELECT THE
APPROPRIATE CASE:
 Child is brought to the Center because the
child is sick (due to illness)
 Every new Illness treat the child as initial visit
 Know the age of the child in order to select the
appropriate chart.
 Decide which age group the child is in:
 *Age 1 week up to 2 month
 * Age 2 month up to 5 years
 If the child is age 2 month up to 5 years
select the ASSESS AND CLASSIFY THE
SICK CHILD AGE 2 MONTH UP TO 5 YEARS.
 “Up to 5 years” means the child has not yet
had fifth birthday.
 A child who is 2 month old would be in the
group 2 months up to 5 years, not in the
group 1 week up to 2 month.
 If the child is not yet 2 month of age, the child
is considered young infant. Use the chart
ASSESSES, CLASSIFY AND TREAT THE
SICK YOUNG INFANT.
The Case Management
Process for the Sick Children
 (Age 2 month up to 5 years)
 Presented in three charts namely:
 ASSESS AND CLASSIFY THE SICK
CHILD
 TREAT THE CHILD
 COUNSEL THE MOTHER
ASSESS AND CLASSIFY the Sick
Child Age 2 Months Up to 5 Years

 Describes how to assess and classify

sick children so that signs of disease are
not overlooked.
 STEPS
Assess & Classify
ASSESS:

 Ask the mother about the child’s problem

are
 * Determine if this is an initial or follow
problem for this problem.
 * If follow-up visit, use the follow-up
instruction on the TREAT THE CHILD
chart
 * If initial visit, assess the child as follows:
 2. Check for the General danger signs – (
Ask/Look)
 * A child with any danger signs needs
URGENT attention. Complete the assessment
and any pre-referral treatment so referral is not
delayed.

 3. Then ask about the main symptoms –

(Ask/ Look/Listen)
4. Ask additional questions to help classify
the illness.
5. Check the child for malnutrition anemia
6. Check the child’s immunization and
Vitamin A status.
7. And assess other problems the mother
has mentioned.
CLASSIFY:

1. Use all boxes that match the child’s symptoms

and problems to classify the Illness.
2. Be sure the child with any danger sign is
referred after the first dose of an appropriate
antibiotic and other treatment.
 Exception: Rehydration of the child according
to Plan C may resolve the danger signs so that
referral is no longer needed.
APPLICATION

Ask the mother what the child’s

problems are:
 Mother and any family member can bring
the child to the health center.
 Children’s visit to the HC for well-child
visit, immunizations and for treatment of
injuries.
 The steps on the ASSESS AND
CLASSIFY chart describe what you
should do when a child is brought to the
HC because he is sick.
 The chart should not be used for a well
child brought for immunization or for a
child with injury or burns.
Steps:
1. Greet the mother appropriately.

 * Know the child’s age (month) to choose the right

management chart.

 * If the child is 2 month up to 5 years, assess and

classify the child according to the steps on the
ASSESS AND CLASSIFY chart.

 * If the child is 1 week up to 2 month, assess and

classify the young infant according to the steps on the
YOUNG INFANT chart.
2. Ask the mother what the child’s problems
are.
 * Record what the mother tells you
about the child’s problem (check, encircle,
N/A)
 * Use good communication skills:
 A - Ask, listen
 P - Praise
 A - Advice
 C - Check Understanding
3. Determine if this is an initial or follow-
up visit for this problem
 * Initial visit- is the child’s first visit for
this episode of an illness or problem.

 * Follow-up visit – the child was

seen few days ago for the same illness.
Check for General Danger
Signs
 Check ALL sick children for General
Danger Signs
 A danger sign is present if :
 The child is not able to feed or
breastfeed
 The child vomits everything
 The child has had convulsions
 The child is abnormally sleepy or
difficult to awaken
 A child with general danger sign has a
serious problem URGENT referral to the
hospital.

 “ASSESS” column – tells us how to

check for general danger sign.
 “CLASSIFY” column
 Classification Tables has 3 rows and it is
color coded (pink, yellow and green).

 The color of the rows tells us quickly if

the child has a serious illness
 = A classification in a pink row
needs urgent attention and
referral or admission for in
patient care. This is a severe
classification.
 = A classification in a yellow row
means that the child needs an
appropriate antibiotic, an oral
anti-malarial or other treatment.
The treatment includes teaching the
mother how to give the oral drugs or
how to treat local infections at home.
The HW advices her about caring for
the child at home and when she
should return.
 = A classification in a green row
means the child does not need
specific medical treatment such as
antibiotic. The health worker
teaches the mother how to care for
her child at home.
 Can also quickly choose the appropriate
treatment.
 Depending on the combination of the
child’s S/S, the child is classified only
once in each classification table.
MANAGEMENT OF
THE SICK YOUNG
INFANT
AGE 1 WEEK UP TO 2
MONTHS
 The process is very similar to the one we
have learned for managing the sick child
age 2 month up to 5 years.
 All the steps are in one chart.
1. Assess
2. Classify
3. Treat
4. Counsel the mother
5. Follow-up
Things to remember:

 General signs are few movements, fever

or low body temperature.
 Mild chest indrawing is normal because
their chest wall is soft.
 Newborn infants are often sick from
conditions related to labor and delivery or
have conditions which require special
management.
ASSESS AND
CLASSIFY THE SICK
YOUNG INFANT
 Check for signs of possible bacterial
infection. Then classify the young infant
based on the signs found.
 Ask about diarrhea. If the infant has
diarrhea, assess the related signs.
Classify the young infant for dehydration.
Also classify the persistent diarrhea and
dysentery if present.
 Check for feeding problem or low weight.
This may include assessing breast
feeding. Then classify feeding.
 Check the young infant’s immunization
status.
 Assess any other problems.
 If you find that the young infant needs
referral, you should continue the
assessment. However, skip the
breastfeeding assessment because it
can take sometime.