Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months

INTRODUCTION
 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)
 M.P. IMR - 56/1000 live births (60 –
Rural, 37 Urban)
(SRS 2013)
2/3rd children of M.P. are malnourished.

 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).
 IMNCI strategy is one of the main interventions under RCH-
II/NRHM, that focuses on preventive, promotive and
curative aspects of program.
 Every year more than 10 million children die in developing
countries before they reach their fifth birthday.
 Perinatal conditions, acute respiratory infections (ARI),
diarrhea, measles and malnutrition are the
commonest causes of morbidity in young children.
(Textbook of PSM, Park’s 22nd edition)

 Inclusion of 0-7 days age group (as against 1 week to 5 years
in IMCI) to address the neonatal mortality challenge.
 The order of training was reversed, starting from the young
infant (0-2 months) to the older child (2 months-5 years).
 The total duration of training was reduced from 11 days to 8
days out of which, half of the training time was earmarked for
the management of the young infants, 0 to 2 months.
 Incorporating National guideline on Malaria, Anemia, Vit. A
supplementation and Immunization schedule.
 Home-based care of newborns and young infants was
included.
nd
The major highlights of Indian
adaptations were as follows:

Difference B/w IMCI and IMNCI
Features Generic IMCI India IMNCI
Coverage of 0 – 6 days No Yes
Basic health worker
module
No Yes
Home visit module by
provider for care of
newborn and young
infants
No Yes
Home visit training No Yes
Duration of training on
newborn and young
infants
2 to 11 days 4 to 8 days
Sequence of training,
behavior change
communication
Child first than young
infants
Newborn/ young infants
than child

Malnutrition*
54%
MAJOR CAUSES OF
NEONATAL AND
CHILDHOOD MORBIDITY
43%
27%
17%
13%
Malnutrition
Fever
ARI
Diarrhoea

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.

• In health facilities, the IMCI strategy promotes
the accurate identification of childhood
illnesses in outpatient settings, ensures
appropriate combined treatment of all major
illnesses, strengthens the counseling of
caretakers, and speeds up the referral of
severely ill children.
• In the home setting, it promotes appropriate
care seeking behaviors, improved nutrition and
preventative care, and the correct
implementation of prescribed care.
• (Textbook of PSM, Park’s 22nd edition)

IMNCI Plus
(National health programs of India, J Kishore 11th edition)
New born and child health
C
A
R
e
at
B
I
R
T
h
I
M
m
U
N
I
Z
A
T
ion
Home and
community
level
Preventive,
Promotive care
Management
of mild illness
Facility care
Out patient
care
Inpatient care
IMNCI
Health system strenthening
BCC & community participation

Why is IMNCI better than single
condition approaches?
• Children brought for medical treatment are often found
suffering from more than one morbid condition, making a
single diagnosis impossible. These children require a
combined therapy for successful treatment. Thus, the need
of the hour is an integrated strategy that combines the
treatment of major childhood illnesses.
•Cost effective
•Emphasizes on
-Prevention of disease
-Promotion of Child health and development
-Provision of Standard Case management

Objectives
1) Reducing infant mortality.
2) Reducing the incidence and seriousness of
illnesses and health problems.
3) Improving growth and development during
the
first five years of a child's life

Components of integrated
approach
IMNCI includes both preventive and curative interventions. The
strategy has the following three components:
1.Health-worker component: Improvements in the case-
management skills of health staff through the provision of
locally adapted guidelines
2.Health-service component: Improvements in the overall
health system required for effective management of neonatal
and childhood illness
3.Community component: Improvements in family and
community health care practices.

Case Management Process
 In IMNCI, only a limited number of carefully-selected clinical
signs are considered, based on their sensitivity and specificity,
to detect the disease. A combination of these signs helps in
arriving at the child's classification, rather than a diagnosis.
 Classification(s) also indicates the severity of the condition. The
classifications are color coded:
A. PINK CLASSIFICATION: suggests hospital referral or admission
(Child needs urgent referral)
B. YELLOW CLASSIFICATION: indicates initiation of treatment (Child
needs specific medical treatment and advise)
C. GREEN CLASSIFICATION: calls for home treatment (Child needs no
medicine, advise home care)

 A sick young infant up to 2 months of age is
assessed for
Possible bacterial infections, diarrhoea ,
jaundice
 Children of age 2 months to 5 years:
Cough or difficult breathing, diarrhoea, fever
&ear problems
 Active participation of caretakers in the
treatment
 Use of limited number of essential drugs

ELEMENTS:-
Assess
Danger signs, nutrition and immunization status
Other problems
Classify
as per Color Coding
Identify
Specific Treatment
Provide Treatment
Pre referral
Medical treatment
Home Management
Counsel
Feeding problems
Mother’s health
Follow-up care(
Textbook of PSM, Park’s 22nd edition)

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? (IMNCI Module 2 WHO, UNICEF,

it is a sign commonly used by health care workers to assess the
degree of fluid loss or dehydration.
I. Locate the area on the child's abdomen halfway between the
umbilicus and the side of the abdomen; then pinch the skin
using the your thumb and finger.
II. Place your hand in such a way that when the skin is pinched,
the fold of skin will be in a line up and down the child's body
and not across the child's body.
III. It is important to firmly pick up all of the layers of skin and the
tissue under them for fifteen to thirty seconds and then
release it.
(IMNCI Module 2 WHO, UNICEF, MOHFW)

TURGOR SIGN
When released, the skin pinch goes back either
• very slowly (longer than 2 seconds),
• slowly (skin stays up even for a brief instant),
• immediately.

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
OR
If infant does not have low weight or any
other severe classification:
- Give fluid for severe dehydration (Plan
C) and then refer to
hospital after rehydration
(IMNCI Module 2 WHO, UNICEF, MOHFW

Two of the
following
signs:
• Restless,
irritable
• Sunken eyes
• Skin pinch
goes
back slowly.
SOME
DEHYDRATIO
N
If infant has low weight or another
severe classification:
- Give first dose of intramuscular
- 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 theway to the hospital
If infant does not have low weight or
another severe classification:
- Give fluids for some dehydration (Plan B)
- Advise mother when to return
immediately(IMNCI Module 2 WHO, UNICEF, MOHFW)

•Not enough signs to
classify as some or
severe dehydration
NO
DEHYDRATION
Give fluids to treat diarrhea at
home
Advise mother when to return
immediately
Follow up in 5 days if not
improving
<PLAN A>

•Diarrhea lasting 14 days or
more
SEVERE
PERSISTENT
DIARRHOEA
 Give first dose of intramuscular
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
Give first dose of intramuscular
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
sugar

COUNSEL THE MOTHER ON THE 4 RULES OF HOME TREATMENT
1 GIVE EXTRA FLUID( AS MUCH AS THE CHILD WILL TAKE )
Breastfeed frequently and for longer at each feed. Give ORS
and clean water in addition to breast milk
2. GIVE ZINC SUPPLEMENTS (Not for infant below 2 months)
3. CONTINUE BREAST FEEDING
4. TELL HER WHEN TO RETURN

Tell the mother to:
* Wash the hands with soap & clean water first.
* In a clean container, first empty the entire packet of mixture and go
on adding water while stirring with a clean spoon to not allow lumps
to be formed
* If the child vomits, wait 10 minutes. Then continue, but more slowly.
* Up to 2 years 50 to 100 ml after each loose stool
* Give from a clean bowl/ cup with a clean spoon from the angle of the
mouth to < 2 yrs age child.
* Make fresh daily & use within 24 hrs. Taste of tears (not more salty
than that).

 Give in clinic recommended amount of ORS over 4-hr
period (which is 200-400 ml for a child whose age is <
4 months or whose weight is <6 kgs.)
 If the child wants more, give more.
 After 4 hrs, reassess the child and classify for
dehydration & select the appropriate plan to continue
treatment.
 Begin feeding the child at the clinic.
If mother has to leave before 4 hrs, show her how to
prepare ORS, tell & ask how much to give in 4 hrs,
explain the above mentioned 4 rules of home
treatment. (IMNCI Module 2 WHO, UNICEF, MOHFW)

Start iv fluid immediately. If child can drink
give ORS by mouth while the drip is set
up.
Give 100ml/kg ringer lactate solution(if not
available then N.saline) in dose divided
as:
30ml/kg in first hour
And rest 70ml/kg in 5 hour ..
Reassess the child in every 15-30 mins
.

Diarrhoea
If persists If stopped
Assess and manage as per intial visit Reinforce exclusive breastfeeding
After two days

Assessment Of Feeding Problem
And Malnutrition

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(IMNCI Module 2 WHO, UNICEF, MOHFW)

Look , Feel:-
Determine weight for age
-Mid Upper Arm
Circumference(MUAC)
MUAC TAPE

Assess Breast Feeding :-
•Has the infant breastfed in previous hour?
•Is the infant able to attach?
To check attachment , look for:
Chin touching breast
Mouth wide open
Lower lip turned outward
More areola visible above than below .

 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 (IMNCI Module 2 WHO, UNICEF, MOHFW)

 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?(IMNCI Module 2 WHO, UNICEF, MOHFW)

SIGNS
CLASSIFY
AS
TREATMENT
•Not able to feed or
•No attachment or
•Not suckling at all
or
•Very low wt for age
Not able to feed –
Possible serious
bact. infection or
Severe
malnutrition
Give first dose of
intramuscular
Treat to prevent low blood
sugar
Warm the young infant by
skin to skin contact if
temperature less than 36.5oC
(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
(IMNCI Module 2 WHO, UNICEF, MOHF

Not well attached to
breast or
• Not suckling effectively
or
• Less than 8
breastfeeds
in 24 hours or
• Receives other foods
or drinks or
• Moderately
underweight
(< -2SD to -3SD) or
• Thrush (ulcers or
white patches in mouth)
or
• Breast or nipple
problems
Feeding
problem or low
weight for age
If not well attached or not suckling
effectively, teach correct positioning
and attachment
If breastfeeding less than 8 times
in 24 hours, advise to increase
frequency of feeding.
If receiving other foods or drinks,
counsel mother about breastfeeding
more, reducing other foods or drinks,
and using a cup and spoon.
• If not breastfeeding at all advise
mother about giving locally
appropriate animal milk and teach
the mother to feed with a cup and
spoon.
If thrush, teach the mother to treat
thrush at home.

If breast or nipple problem, teach the
mother to treat breast or nipple
problems.
If low weight for age, teach the
mother how to keep the young infant
with low weight warm at home
Advise the mother to give home care
for the young infant
Advise mother when to return
immediately
Follow up any feeding problem or
thrush in 2 days
Follow up low weight for age in 14
days
•Not low weight for
age and no signs of
inadequate feeding
No feeding
problem
Advise the mother to give home care
for theyoung infant
Advise mother when to return
immediately

FOLLOW –UP CARE

Feeding Problem
Reassess feeding
Ask about any feeding problems found
on the initial visit.
Counsel the mother, ask her to return
back again in 2 days.
Exception :If you do not think that
feeding will improve or if young infant has
lost weight: - refer to hospital.

Teach correct positioning and
attachment for breastfeeding.
 Show the mother how to hold
her infant
 With the infant head and body
straight.
 Facing her breast, with infant’s
nose opposite her nipple
 With infant’s body close to her
body.
 Supporting infant’s whole body.

Show her how to help
the infant to attach.
Infant’s chin should touch
her breast
Mouth should be wide open.
Upper areola should be
visible more than the lower
areola.
Lower lip should be turned
outward.

Look for signs of effective
suckling.
The baby takes slow and deep sucks (the
pauses are to allow more milk to flow into
the lactiferous sinuses/ milk ducts)
You can see or hear baby swallowing
The baby cheeks are not drown inwards
and are rounded during feed
To treat thrush (ulcers or
white patches in mouth)
Apply gentian violet 0.25% paint twice
daily.
The mother should :
•Wash hands
•Wash mouth
•Paint the mouth with gentian violet.(IMNCI Module 2 WHO, UNICEF, MOHFW)

CHECK FOR POSSIBLE
BACTERIAL
INFECTIONS/JAUNDICE

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?(IMNCI Module 2 WHO, UNICEF, MOHFW)

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
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
(A) CLASSIFY ALL YOUNG INFANTS

Look for chest indrawing when child breaths IN.
The child has indrawing if the lower chest goes in when the child breathes in
Chest indrawing occurs when the effort required to breathe in,is much greater than
normal
CHEST INDRAWING

•Umbilicus red or
draining pus
•Pus discharge from ear
or
•< 10 skin pustules
LOCAL
BACTERIA
L
INFECTION
Give oral co-
trimoxazole or
amoxycillin for 5
days
Teach mother to treat
local infections at
home
Follow up in two
days
Umbilicus
red
Draining
pus

SIGNS CLASSIFYAS 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
JAUNDICE

•Temperature
between 35.5-36.5
degree Celsius
LOW BODY
TEMPERATURE
Warm the young infant by
skin contact for 1 hr
Treat low blood sugar
(C) IF THE TEMPERATURE IS BETWEEN 35.5- 36.5 DEGREE CELCIUS
12

Teach the mother to give oral drugs at
home
Tell the mother the reason for giving the
drug to infant.
Demonstrate how to measure a dose.
Watch the mother practice measuring a
dose by herself.
Ask the mother to give the first dose to
her infant.
Explain that all the oral drug tablets or
syrups must be used to finish the course of
treatment.
Treat The Young Infant For Local
Infections At Home

Local bacterial infections
Umbilicus red or draining pus
>10 or big boil
<10 and no big boil
Remains or worse
refer to hospital
Improved,continue
treatment
Skin pustules Ear Discharge
Refer to hospital Continue treatment
Continue wicking
dry the ear
Follow-Up Care

Follow up
Jaundice
Are the palms and soles yellow
If yes or age 14 days or more If no or age<14 days
Refer to hospital Advice home care

CHECK FOR POSSIBLE
HYPOTHERMIA

If a baby has a temperature of less than 36.5°C the
baby has ‘hypothermia’.
1) Mild hypothermia (36.0°C to 36.4°C)
2) Moderate hypothermia (32°C to 36.0°C)
3) Severe hypothermia (<32°C)
WHAT IS HYPOTHERMIA

Large surface area of babies compared to their weight.
• Limited heat generation mechanism.
• Vulnerability to getting exposed.
• Decreased subcutaneous fat and brown fat.
• Poorer homeostatic response to hypothermia and early exhaustion of
metabolic store like glucose.
CAUSES OF HYPOTHERMIA

Axillary (standard method)
• Rectal
• Skin
• Human touch-
• abdomen, feet and hands are warm- Normal
• abdomen is warm but feet and hands are cold-
Cold stress
•abdomen, feet and hands are cold-
Hypothermia
METHODS OF TEMPERATURE
MEASUREMENT

Warm Chain- It is a sequence of ten steps-
1) Warm delivery room
2) Warm Resuscitation
3) Immediate drying
4) Skin to skin contact
5) Breastfeeding
6) Bathing postponed
7) Appropriate clothing
8) Mother and baby together
9) Professional alertness
10) Warm transportation
PREVENTION OF
HYPOTHERMIA-

Kangaroo mother care for low birth
weight babies, was introduced in
COLUMBIA in 1979, by Dr’s Hector
Martinez and Edzar Rey.
KANGAROO MOTHER
CARE

• Skin-to-skin contact between mother and baby
is called Kangaroo Mother Care.
• It is the most practical, preferred method of
warming a hypothermic infant in a primary
health care facility.

PROCEDURE-
•Provide privacy to the mother. If mother is not
available then it may be provided by father or
any other adult.
•Request the mother to sit comfortably.
•Undress the baby gently and place the baby
prone on mother`s chest in upright and
extended posture, between her breast, in skin
to skin contact, turn baby`s head to one side
to keep airway clear.
• cover the baby with mother`s gown and wrap
the baby mother duo with an added blanket or
shawl.
• if possible warm the room(>25 c) with a
heat device.

•Reassess after 1 hour.
 Look for signs of possible serious bacterial
infection.
 Measure axillary temperature (or feel for low
body temperature)
• If signs present or temperature still below 36.50c
refer urgently after giving pre-referral treatment.

1) Mild hypothermia (36.0°C to
36.4°C)
 Skin-to-Skin contact is the best way to
keep a baby warm and the best way to ‘re-
warm’ a baby who is cold to touch.
2) Moderate hypothermia (32°C to
36.0°C)
Warm the young infant using Skin to Skin
contact .
If Skin to Skin contact is not possible,
radiant warmer may be used if available.
Encourage mother to breastfeed more
frequently.
If the baby’s temperature is not up to
36.50C or more after 2 hours of
‘rewarming’,reassess the baby for other
problems.
MANAGEMENT OF
HYPOTHERMIA

3) Severe hypothermia (<32°C)
Remove cold or wet clothing. Dress in warm clothes and a cap,
and cover with a warm blanket.
Warm immediately using a pre warmed radiant warmer.
Check and treat for hypoglycemia .
Treat for sepsis.
Start IV fluids.
Provide oxygen if indicated .
Monitor temperature of the baby every ½ hourly.

Counsel The Mother FOR HOME
CARE
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.

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

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.

Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months

Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months

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Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months