IMNCI and its recent advances with current status of trained personnel and classification of 5 preventable diseases.

1. Integrated Management of Neonatal &
Childhood Illness(IMNCI)
SPEAKER:- Shubhanshu Gupta
TEACHER I/C:- Dr.Dheeraj Mahajan
DATE:- 21/10/2014
1

2. Contents
• Introduction
• IMNCI
- Components
- Guidelines
- Principles Of Integrated Care
- Elements Of Case Management Process
- Case Management Process
• F- IMNCI
• C-IMNCI
• IMNCI plus
• IMNCI in UP(CCSP)
2

3. Introduction
• Every year more than 10 million children die in developing
countries before they reach their fifth birthday.
• 7 in 10 of these deaths are due to five preventable and treatable
conditions.
Pneumonia, diarrhea, malaria, measles and malnutrition – and
often to a combination of these conditions.
• 3 out of 4 of these children suffer from one of these five
conditions.
3

4. 4

5. • 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) in 2012,
which was 47 in 2010.
World IMR-35/1000 live births
• India PMR=32,NMR=33,U5MR=59 per 1000 live births.
• In INDIA- M.P. has the highest IMR followed by
ASSAM,ORISSA and UP.
MP=56,ASSAM=55,ORISSA and UP=53/1000 live births. 5

6. • Projections based on the 1996 analysis indicate that common
childhood illnesses will continue to be major contributors to child
deaths through the year 2020 unless greater efforts are made to
control them.
• This assumption makes a strong case for introducing new strategies
to significantly reduce child mortality and improve child health and
development.
• 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)-main intervention under RCH-II/NRHM ,that
focuses on preventive,promotive and curative aspects of program.
6

7. Why Newborn in India
1st Hour 1st Day 1stWeek 1st Month
Reasons for the delay in assessment and accessibility of newborn to
reach healthcare setting:
1.Starting of a problem
2. Delay in recognizing problem
3.Home based treatment
4.Delay in selecting health facility
5.Treatment from traditional advisors and village doctors
6.Delay in selecting formal health facility causing delay in treatment and increased cost
7.Increased chances of death of newborn.
7

8. 8

9. 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.
9

10. Difference between IMCI and IMNCI
Features: WHO – UNICEF IMCI IMNCI
Coverage of 0 to 6 days (early
newborn period)
No Yes
Basic Health Care Module NO Yes
Home visit by the provider for
newborn and Young Infant
No Yes
Training
Training Home based Care No Yes
Training days for newborn and
young infants
2 out of 11 days 4 out of 11 days
Sequence of training Child (2 months to 5 years of
age) then Young infant ( 7 days
to 2 months of age)
Newborn and young infants (0
to 2 months).Then Child (from
2 months to 5 years of age.)
10

11. Evidence-based, syndromic approach to case management includes rational, effective
and affordable use of drugs and diagnostic tools.
An evidence-based syndromic approach can be used to determine the:
• Health problem(s) the child may have.
• Severity of the child’s condition, and
• Actions that can be taken to care for the child (e.g. refer the child immediately,
manage with available resources, or manage at home).
In addition, IMNCI promotes:
• Adjustment of interventions to the capacity of the health system, and
• Active involvement of family members and the community in the health care process.
11
Guidelines for IMNCI

12. IMCI Process:
12

13. Principles of integrated care
• All sick young infants up to 2 months of age must be assessed for
“possible bacterial infection / jaundice”. Then they must be
routinely assessed for the major symptom “diarrhoea”.
• All sick children age 2 months up to 5 years must be examined for
“general danger signs” which indicate the need for immediate
referral or admission to a hospital. They must then be routinely
assessed for major symptoms: cough or difficult breathing,
diarrhoea, fever and ear problems.
• All sick young infants and children 2 months up to 5 years must
also be routinely assessed for nutritional and immunization status,
feeding problems, and other potential problems.
13

14. Principles of integrated care
(Contd. .)
A combination of individual signs leads to a child's classification(s)
rather than diagnosis.
- needs urgent hospital referral or admission
( classifies as and colour coded pink)
- needs specific medical Rx or advice
(classified as and colour coded yellow)
- can be managed at home
(classified as and colour coded green)
14

15. Principles of integrated care
(Contd. .)
• IMNCI use a limited number of essential drugs and encourage
active participation of caretakers in the treatment.
• IMNCI address most, but not all, of the major reasons a sick child
is brought to a clinic.
• One of essential component of IMNCI is the counselling of
caretakers about home care,feeding,fluids and when to return to
health facility. 15

16. Goals of IMNCI
• Standardized case management of sick newborns
and children
• Focus on the most common causes of mortality
• Nutrition assessment and counselling for all sick
infants and children
• Home care for newborns to
– promote exclusive breastfeeding
– prevent hypothermia
– improve illness recognition & timely care
seeking
16

17. Elements of case management
process
• Assess - Child by checking for danger signs by history and
examination.
• Classify - Child's illness by color coded triage system.
• Identify - Specific treatments.
• Treatments- Instructions of oral drugs, feeding & fluids.
• Counsel - Mother about breast feeding & about her own health as
well as to follow further instructions on further child care.
• Follow up care - Reassess the child for new problems.
17

18. The CASE MANAGEMENT PROCESS Is Used To
Assess And Classify Two Age Groups
Management Of The Young Infant Age Up To 2
Months Is Presented On Two Charts
 Assess and classify the sick young infant age up to 2 months.
 Treat the young infant and counsel the mother.
18

19. Assess and classify the sick young
infant up to 2 months
19

20. 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?
20

21. 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
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 hos2p1ital.

22. •Umbilicus red or
draining pus
•Pus discharge from ear
or
•< 10 skin pustules
LOCAL
BACTERIAL
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
22

23. SIGNS CLASSIFY AS 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
Advise mother when to return
immediately
Follow up in 2 days
23

24. •Temperature
between 35.5-
36.4degree Celsius
LOW BODY
TEMPERATURE
Warm the young infant by
skin contact for 1 hr and
REASSESS
Treat to prevent low
blood sugar
24

25. 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?
25

26. Classification:
Signs Classify treatment
Two of the
SEVERE
following
DEHYDRATION
signs:
Lethargic or
unconscious
Sunken eyes
Skin goes back
very slowly
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
26

27. •Not enough signs to
classify as some or
severe dehydration
NO
DEHYDRATION
Give fluids to treat diarrhea at
home(PLAN A)
Advise mother when to return
immediately
Follow up in 5 days if not
improving
Two of the following
signs for
restless, irritable
sunken eyes
skin pinch goes
back slowly
SOME
DEHYDRATION
Give first dose of intramuscular
ampicillin and gentamicin.
Give fluids to treat some
dehydration(PLAN B)
Refer URGENTLY to hospital
with mother giving frequent oral
sips of ORS.
27

28. •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
Treat to prevent low blood sugar
28

29. 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 infant?
29

30. Look , Feel:-
Determine weight for age
-Mid Upper Arm
Circumference(MUAC)
MUAC TAPE
30

31. 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 .
31

32. • 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
32

33. • 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?
• Classify feeding as:
 Not able to feed-serious bacterial infection or severe malnutrition
 Feeding problem or low weight for age
 No feeding problem
33

34. Immunization Status
CHECK IMMUNIZATION
STATUS:
IMMUNIZATION
SCHEDULE
• Birth - BCG,OPV(0)
HepB1
• 6 weeks - DPT1, OPV1,
HepB2
34

35. Counsel The Mother
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.
35

36. 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
36

37. 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.
37

38. MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS
Name:___________ Age:___________ Weight:____________________kg________________________Temperature:_______________C
ASK: What are the infant's problems?__________________________________ Initial visit?_________________ Follow-up Visit?______________
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR POSSIBLE BACTERIAL INFECTION
•Has the infant had convulsions?
•Count the breaths in one minute. _______ breaths per minute
Repeat if elevated ________ Fast breathing?
•Look for severe chest indrawing.
•Look for nasal flaring.
•Look and listen for grunting.
•Look and feel for bulging fontanelle.
•Look for pus draining from the ear.
•Look at umbilicus. Is it red or draining pus?
Does the redness extend to the skin?
•Fever (temperature 37.5 C or feels hot) or low body temperature
(below 35.5° C or feels cool).
•Look for skin pustules. Are there many or severe pustules?
•See if young infant is lethargic or unconscious.
•Look at young infant's movements. Less than normal?
DOES THE YOUNG INFANT HAVE DIARRHOEA?
•For how long? _______ Days
•Is there blood in the stools?
Yes _____ No ______
•Look at the young infant's general condition. Is the infant: Lethargic
or unconscious?
Restless or irritable?
•Look for sunken eyes.
•Pinch the skin of the abdomen. Does it go back: Very slowly (longer
than 2 seconds)?
Slowly?
38

39. THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
•Is there any difficulty feeding? Yes_____ No______
•Is the infant breastfed? Yes_____ No_____
•IfYes, how many times in 24 hours?_____ times
•Does the infant usually receive any
other foods or drinks? Yes_____ No_____
If Yes, how often?
•What do you use to feed the child?
ASSESS BREASTFEEDING:
•Has the infant breastfed in the previous hour?
•Determine weight for age. Low _____ Not Low _____
If infant has not fed in the previous hour, ask the mother to put her
infant to the breast. Observe the breastfeed for 4 minutes.
•Is the infant able to attach? To check attachment, look for:
— Chin touching breast Yes _____ No
_____
— Mouth wide open Yes _____ No _____
— Lower lip turned outward Yes _____ No _____
— More areola above than below the mouth
Yes _____ No _____
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
•Look for ulcers or white patches in the mouth (thrush).
CHECK THE YOUNG INFANT'S IMMUNIZATION STATUS
BCG DPT1 DPT2
OPV 0 OPV 1 OPV 2
Circle immunizations needed today. Return for next
immunization on:
(Date)
MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS
Name:___________ Age:___________ Weight:____________________kg________________________Temperature:_______________C
ASK: What are the infant's problems?__________________________________ Initial visit?_________________ Follow-up Visit?______________
ASSESS (Circle all signs present) CLASSIFY
If the infant has any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or drinks, or is low weight for age AND has no indications to refer urgently to
hospital:
39

40. TREAT
Return for follow-up on _________________
Give any immunization/s needed today.
40

41. ASSESS And CLASSIFY THE SICK CHILD
AGE From 2 Months Up To 5 YEARS
41

42. General Danger Signs
ASK:
• Is the child able to drink or
breastfeed?
• Does the child vomit
everything?
• Has the child had convulsions?
LOOK:
• See if the child is lethargic or
unconscious
42

43. Cough or Difficult Breathing?
IF YES, ASK:
• For how long?
LOOK, LISTEN, FEEL:
• Count the breaths in one minute.
2-12 months = fast breathing >/= 50/min
12 months-5yrs = fast breathing >/=
40/min
• Look for chest indrawing
• Look and listen for stridor
Classify COUGH or DIFFICULT BREATHING
43

44. Classification Table For Cough Or Difficult Breathing
SIGNS CLASSIFY AS IDENTIFY TREATMENT
•Any general danger
sign or
•Chest indrawing or
•Stridor in calm child.
SEVERE
PNEUMONIA
OR VERY
SEVERE DISEASE
•Give first dose of an appropriate
antibiotic.
•Refer URGENTLY to hospital.
•Fast breathing
PNEUMONIA
•Give an appropriate oral antibiotic
for 5 days.
•Soothe the throat and relieve the
cough with a safe remedy.
•Advise mother when to return
immediately.
•Follow-up in 2 days.
No signs of
pneumonia
or very severe
disease.
NO PNEUMONIA:
COUGH OR COLD
•If coughing more than 30 days,
refer for assessment.
•Soothe the throat and relieve the
cough with a safe remedy.
•Advise mother when to return
44

45. Diarrhea
Does the child have diarrhea?
IF YES, ASK:
•For how long?
•Is there blood in the stool?
LOOK, LISTEN, FEEL:
Look at the child’s general condition, is
the child:
Lethargic or unconscious?
Restless or irritable?
Look for sunken eyes
Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
Pinch the skin of the abdomen.
Does it go back:
Very slowly (> than 2 secs)?
Slowly?
45

46. Two of the following signs:
Lethargic or unconscious
Sunken eyes
Not able to drink or drinking
poorly
Skin pinch goes back very
slowly
Classification Table For Dehydration
SEVERE
DEHYDRATION
If child has no other severe classification:
— Give fluid for severe dehydration (Plan C).
OR
If child also has another severe classification:
— Refer URGENTLY to hospital with mother giving
frequent sips of ORS on the way.
Advise the mother to continue breastfeeding
If child is 2 years or older and there is cholera in
your area, give antibiotic for cholera.
Two of the following signs:
Restless, irritable
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back slowly
SOME
DEHYDRATION
Give fluid and food for some dehydration (Plan B).
If child also has a severe classification:
— Refer URGENTLY to hospital with mother
giving frequent sips of ORS on the way.
Advise the mother to continue breastfeeding
Advise mother when to return immediately.
Follow-up in 5 days if not improving.
Not enough signs to
classify as some or
severe dehydration. NO
DEHYDRATION
Give fluid and food to treat diarrhoea at home (Plan A).
Advise mother when to return immediately.
Follow-up in 5 days if not improving.
SIGNS CLASSIFY AS
IDENTIFY TREATMENT
46

47. Classification Table For Persistent Diarrhoea and dysentery
SIGNS CLASSIFY AS IDENTIFY TREATMENT
47
Dehydration present SEVERE
PERSISTENT
DIARRHEA
Treat dehydration before
referral unless the child has
another severe classification.
Refer to hospital.
No dehydration PERSISTENT
DIARRHEA
Advise the mother on feeding
a child who has PERSISTENT
DIARRHOEA.
Follow-up in 5 days.
Blood in the stool Dysentery
Treat for 5 days with
an oral antibiotic
recommended for
Shigella in your area.
Follow-up in 2 days.

48. Does the child have FEVER? Fever
IF YES, decide the malaria risk: high or low
THEN ASK:
•For how long?
•If more than 7 days, has fever been
present every day?
•Has the child had measles within the
last 3 months?
LOOK AND FEEL:
Look for runny nose
Look or feel for stiff neck
LOOK FOR SIGNS OF MEASLES
has measles now or within the last 3 months
-Rash -Mouth ulcers
-Cough -Pus from eyes
-Runny nose -Clouding of cornea
-Red eyes 48

49. Classification Table For High Malaria Risk
•Any general danger
sign or
•Stiff neck or
• bulging fontanelle VERY SEVERE
FEBRILE
DISEASE
•Give first dose of an appropriate
antibiotic.
•Treat the child to prevent low blood
sugar.
•Give one dose of paracetamol in clinic
for high fever (38.5° C or above).
•Refer URGENTLY to hospital.
•Fever (by history or
feels hot or
temperature above
37.5
MALARIA
•Give oral antimalarials for HIGH
RISK MALARIA.
•Give one dose of paracetamol
•Advice mother when to return
immediately
•Follow up in 2 days
.
SIGNS CLASSIFY AS
IDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
49

50. Classification Table For Measles
(If Measles Now Or Within The Last 3 Months)
•Any general danger sign
or
•Clouding of cornea or
•Deep or extensive
mouth ulcers.
SEVERE
COMPLICATED
MEASLES***
•Give vitamin A.
•Give first dose of an appropriate
antibiotic.
•If clouding of the cornea or pus
draining from the eye, apply tetracycline
eye ointment.
•Refer URGENTLY to hospital.
•Pus draining from the
eye or
•Mouth ulcers
MEASLES WITH
EYE OR MOUTH
COMPLICATIONS
***
•Give vitamin A.
•If pus draining from the eye, treat eye
infection with tetracycline eye ointment.
•If mouth ulcers, treat with gentian violet.
•Follow-up in 2 days.
•Measles now or within
the last 3 months. MEASLES
•Give vitamin A.
SIGNS CLASSIFY AS
IDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
50
*** Other important complications of measles—pneumonia, stridor, diarrhoea, ear infection, and malnutrition—are classified in
other tables.

51. Ear Problem
Does the child have an EAR
PROBLEM?
IF YES, ASK
•Is there ear pain?
•Is there ear discharge? If yes, for
how long?
LOOK AND FEEL:
Look and pus draining from the ear
Feel for tender swelling behind the
ear.
51

52. Classification Table For Ear Problem
•Tender swelling
behind the ear. MASTOIDITIS
•Give first dose of an appropriate
antibiotic.
•Give first dose of paracetamol for pain.
•Refer URGENTLY to hospital.
•Pus is seen draining
from the ear and
discharge is reported
for less than 14 days,
or
•Ear pain.
ACUTE EAR
INFECTION
•Give an oral antibiotic for 5 days.
•Give paracetamol for pain.
•Dry the ear by wicking.
•Follow-up in 5 days.
•Pus is seen draining
from the ear and
discharge is reported
for 14 days or more.
CHRONIC EAR
INFECTION
•Dry the ear by wicking.
•Follow-up in 5 days.
•No ear pain and No
pus seen draining from
the ear.
NO EAR
INFECTION
No additional treatment
SIGNS CLASSIFY AS
IDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
52

53. Malnutrition and Anemia
CHECK FOR MALNUTRITION AND
ANEMIA
LOOK AND FEEL:
• Look for visible severe wasting
• Look for palmar pallor. Is it:
• Severe palmar pallor?
• Some palmar pallor?
• Look for edema of both feet
• Determine weight for age
CLASSIFY NUTRITIONAL STATUS
53

54. Classification Table For Malnutrition And Anaemia
•Visible severe wasting or
•Severe palmar pallor or
•Oedema of both feet.
SEVERE
MALNUTRITION
OR SEVERE
ANAEMIA
•Give Vitamin A.
•Refer URGENTLY to hospital.
•Some palmar pallor or
•Very low weight for age.
ANAEMIA OR VERY
LOW WEIGHT
•Assess the feeding
— If feeding problem, follow-up in 5 days.
•If pallor:
— Give iron.
— Give oral antimalarial if high malaria risk.
— Give mebendazole if child is 2 years or older and
has not had a dose in the previous 6 months.
•Advise mother when to return immediately.
•If pallor, follow-up in 14 days.
If very low weight for age, follow-up in 30 days.
•Not very low weight for
age and no other signs or
malnutrition.
NO ANAEMIA AND
NOT VERY LOW
WEIGHT
•If child is less than 2 years old, assess the
feeding and counsel the mother on feeding.
— If feeding problem, follow-up in 5 days.
•Advise mother when to return immediately.
SIGNS CLASSIFY AS
IDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
54

55. Immunization Status
CHECK IMMUNIZATION
STATUS:
IMMUNIZATION
SCHEDULE
• Birth - BCG, OPV 0
• 6 weeks - DPT1, OPV1,
HepB1
•10 weeks - DPT2,
OPV2,
HepB2
•14 weeks - DPT3, OPV3,
HepB3
•9 months – measles+ vit A
•16-18 months-DPTbooster,OPV
•60 months-DT 55

56. Counselling a mother or caretaker
• Ask and Listen
• Praise
• Advice
• Check
Essential elements-
• Teach how to give oral drugs
• Teach how to treat local infection
• Teach how to manage breast or nipple problem
• Teach correct positioning and attachment for breastfeeding
• Counsel on other feeding problems
• Advise when to return
• Counsel the mother about her own health
56

57. GOOD CHECKING QUESTIONS POOR QUESTIONS
How will you prepare the ORS solution? Do you remember how to mix the
ORS?
How often should you breastfeed your child? Should you breastfeed your child?
On what part of the eye do you apply Have you used ointment on your child
the ointment? before?
How much extra fluid will you give after each Do you know how to give extra
loose stool? fluids?
Why is it important for you to wash your hands? Will you remember to wash your
hands?
57

58. Feeding Recommendations
1. Upto 6 months-exclusive breast feeding
2. 6m-upto 12 m-breastfeed+ one katori serving*( 3 times/day if
breastfeed or 5 times/day if not breastfeed)
3. 12m-up to 2 yrs-breastfeed+food from family pot+one and a half
katori serving*(5 times/day)
4. 2 yrs and older- family food at 3 meals each day+ twice nutritious
food
*-mashed roti/rice/bread/biscuit mixed in sweet milk or in thick dal
with ghee or offer banana/mango/papaya or dalia/halwa/kheer in
milk
58

59. Follow-up Visit Table In The Counsel The Mother Chart
If the child has: Return for follow-up in:
PNEUMONIA
DYSENTERY
MALARIA, if fever persists
FEVER—MALARIA UNLIKELY, if fever
persists
MEASLES WITH EYE OR MOUTH
COMPLICATIONS
2 days
PERSISTENT DIARRHOEA ACUTE EAR
INFECTION
CHRONIC EAR INFECTION
FEEDING PROBLEM
ANY OTHER ILLNESS, if not improving
5 days
VERY PALOR 14 days
LOW WEIGHT FOR AGE 30 days
59

60. Advise to return immediately
60

61. MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Name: ____________________________________________________________________Age:____________________Weight:_______kg Temperature:________ C
ASK: What are the child's problems?_______________________________________________________________________Initial visit?________________Follow-up Visit?__________
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED VOMITS EVERYTHING
CONVULSION
LETHARGIC OR UNCONSCIOUS
General danger signs
present?
Yes ___ No ___
Remember to use
danger sign when
selecting classifications
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING?
•For how long? ____ Days
Yes ___ No ___
•Count the breaths in one minute.
________ breaths per minute. Fast breathing?
•Look for chest indrawing.
•Look and listen for stridor.
DOES THE CHILD HAVE DIARRHOEA?
•For how long? _____ Days
•Is there blood in the stools?
Yes ___ No ___
•Look at the child's general condition. Is the child:
Lethargic or unconscious?
Restless or irritable?
•Look for sunken eyes.
•Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
•Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5 C or above) Yes ___ No ___
Decide Malaria Risk: High Low
•For how long? _____ Days
•If more than 7 days, has fever been present every day?
•Has child had measles within the last three months?
If the child has measles now
or within the last 3 months:
•Look or feel for stiff neck.
•Look for runny nose.
Look for signs of MEASLES:
Generalized rash and
One of these: cough, runny nose, or red eyes.
•Look for mouth ulcers.
If Yes, are they deep and extensive?
•Look for pus draining from the eye.
•Look for clouding of the cornea.
61

62. DOES THE CHILD HAVE AN EAR PROBLEM?
•Is there ear pain?
•Is there ear discharge?
IfYes, for how long? ___ Days
Yes___ No___
•Look for pus draining from the ear.
•Feel for tender swelling behind the ear.
THEN CHECK FOR MALNUTRITION AND ANAEMIA •Look for visible severe wasting.
•Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
•Look for oedema of both feet.
•Determine weight for age.
Very Low ___ Not Very Low ___
CHECK THE CHILD'S IMMUNIZATION STATUS
_____ ______ ______ ______
BCG DPT1 DPT2 DPT3
_______ _______ ______ ______
________
OPV 0 OPV 1 OPV 2 OPV
3 Measles
Circle immunizations needed today. Return for next immunization
on:
(Date)
•Do you breastfeed your child? Yes____ No ____
IfYes, how many times in 24 hours? ___ times.
Do you breastfeed during the night? Yes___ No___
•Does the child take any other food or fluids? Yes___ No ___
IfYes, what food or fluids?
____________________________________________________
____________________________________________________
How many times per day? ___ times.
What do you use to feed the child? _____________________
If very low weght for age: How large are servings?
_________________________________________________
Does the child receive how own serving? ________________
Who feeds the child and how? ________________________
•During the illness, has the child's feeding changed?
Yes ____ No ____
If Yes, how?
FEEDING PROBLEMS
ASSESS CHILD'S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years old
62

63. TREAT
Return for follow-up on ______________
Advise mother when to return immediately.
Give any immunization/s needed today.
Feeding Advice
63

64. Steps To Refer Young Infant /Child
To The Hospital
 Explain the mother the
need for referral, and get
her agreement to take the
child.
 Calm the mother’s fears.
 Write a referral note for
the mother to take with
her to hospital and give it
to doctor.
 Give the mother any
supplies and instructions
needed to care for child
on the way to hospital.
The Referral Note Should Include:
 Name and age of the child;
 Date and time of referral;
 Description of the child's problems;
 Reason for referral (symptoms and
signs leading to severe
classification);
 Treatment that has been given;
 Any other information that the
referral health facility needs to know
in order to care for the child, such as
earlier treatment of the illness or any
immunizations needed.
64

65. IMNCI: What Does It Offer?
• Assessment & classification of all children presenting to the
physician
• Initiating treatment for all children
– Counseling
– Initiate Drug treatment
– Pre-referral treatment and referral advice for serious conditions
– Management where referral is not possible
65

66. IMNCI: What it does not offer?
• Management of serious sick child:
severe pneumonia, severe febrile illness, severe
malnutrition, severe persistent
diarrhoea, sick young infant with sepsis Severe Jaundice
• Care at Birth for all newborns
• Management of Birth asphyxia
• Emergency Triage & treatment(ETAT)
66

67. F-IMNCI
• F- IMNCI is an integration of the existing IMNCI package and the Facility
Based Care package in to one.
• From November 2009 IMNCI has been re -baptized as F-IMNCI, (F -Facility)
with added component of:
1. Asphyxia Management and
2. Care of Sick new born at facility level, besides all other components
included under IMNCI
• Majority of the health facilities (24x7 PHCs, FRUs, CHCs and District
hospitals) do not have trained paediatricians to provide specialized care to the
referred sick newborns and children, the F-IMNCI training will therefore help in
skill building of the medical officers and staff nurses posted in these health
facilities to provide this care.
67

68. Components of F-IMNCI
• Skill based training
• Improvements to the health system : Logistics/Manpower/
Referral mechanisms
• Improvement of Family and Community Practices
68

69. Core competencies
IMNCI Facility based care
1 Understand the IMNCI process and
rationale and know how to use the
IMNCI chart
Care at birth
2 Communicate with care-taker ETAT (Emergency Triage and
Treatment)
3 Danger signs in children and
severe signs in newborns and
young infants
Using essential equipment
4 Not many essential procedures Essential Procedures
5 Malnutrition and anaemia Manage referrals
6 Immunization* and vitamin A
supplementation
Severe Acute malnutrition
7 Infant & young child feeding Infant & young child feeding
69

70. C - IMNCI: Community and Household
IMNCI:
• Community IMNCI is basically Component 3 of the IMCI
Package.
• It aims at improving family and community practices by
promoting those Practices with the greatest potential for
improving child survival, growth and development.
• C-IMCI seeks to strengthen the linkage between health services
and communities, to improve selected family and community
practices and to support and strengthen community-based
activities.
70

71. C - IMNCI: cont.…
COMPONENTS:
• The promotion of growth and development of the
child
• Disease prevention
• Appropriate care at home
• Care-seeking outside the home
71

72. IMNCI Plus
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 strengthening
BCC & community participation
72

73. Training - Child health
TRAINING STATES DISTRICTS NO.
TRAINED
IMNCI 28 433 490000
PRE SERVICE
IMNCI
8 STATES-
79MEDICAL
COLLEGES
4000
73

74. Implementation Of IMNCI In Uttar
Pradesh
• Uttar Pradesh runs a Comprehensive Child Survival Project(CCSP) where the
IMNCI training module has been expanded to include birth preparedness and
essential care at birth.
• IMR =53(2013) as compared to 57(2011)
• NMR=42(2013) as compared to 47(2011)
• U5MR=90(2013) as compared to 92(2011)
• MMR= 359(2012).
• Involvement of CCSP has really brought down the mortality rates, still the
expansion is required to meet the target.
74

75. Components of CCSP
four components:
1. IMNCI
2. ANC(ante-natal care)
3. HBNBC(home based new born care)
4. BCC(behavior change communication)
75

76. References
1. Integrated management of neonatal and childhood illness. Modules 1 to 9. Ministry
of health & Family welfare, Government of India, New Delhi. 2009.
2. Student’s handbook for IMNCI. Ministry of health & Family welfare, Government
of India, New Delhi. 2007.
3. Facility based newborn care operational guide. Ministry of health & Family
welfare, Government of India, New Delhi. 2011.
4. Home based newborn care operational guidelines. Ministry of health & Family
welfare, Government of India, New Delhi. 2011.
5. Park K . Textbook of Preventive and Social Medicine. 21st ed. Jabalpur: Bhanot;
2009. p. 414,530,550.
6. Current statistical data on IMR and U5MR from www.worldbank.org (data 2012-
13) accessed on 20-12-2013 at 2:30 am.
7. Ingle GK, Malhotra C. Integrated management of neonatal and childhood illness:
An overview. IJCM 2007 Apr;32(2):108-110.
76

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78. 78