integrated management of neonatal and childhood illness(IMNCI)

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

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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 1 st Hour 1 st Day 1 st Week 1 st 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

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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 IM N CI 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 hospital. 21

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. I s 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 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 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 Moth er 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. 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? 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 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. 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 immediately. Follow-up in 5 days if not improving. Classification Table For Cough Or Difficult Breathing SIGNS CLASSIFY AS IDENTIFY TREATMENT 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 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. Classification Table For Dehydration SIGNS CLASSIFY AS IDENTIFY TREATMENT 46

47. SIGNS CLASSIFY AS IDENTIFY TREATMENT Classification Table For Persistent Diarrhoea and dysentery 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. Fever Does the child have 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. 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.) Classification Table For High Malaria Risk 49

50. 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.) Classification Table For Measles (If Measles Now Or Within The Last 3 Months) *** Other important complications of measles—pneumonia, stridor, diarrhoea, ear infection, and malnutrition—are classified in other tables. 50

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. 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.) Classification Table For Ear Problem 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. 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.) Classification Table For Malnutrition And Anaemia 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. How will you prepare the ORS solution? Do you remember how to mix the ORS? GOOD CHECKING QUESTIONS POOR QUESTIONS 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 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. 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 Follow-up Visit Table In The Counsel The Mother Chart 59

60. Advise to return immediately 60

61. 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? Name: ____________________________________________________________________Age:____________________Weight:_______kg Temperature:________ C ASK: What are the child's problems?_______________________________________________________________________Initial visit?________________Follow-up Visit?__________ ASSESS (Circle all signs present) CLASSIFY MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS 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. DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5 C or above) Yes ___ No ___ 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: Asphyxia Management and 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. COMPONENTS: The promotion of growth and development of the child Disease prevention Appropriate care at home Care-seeking outside the home C - IMNCI : cont.… 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: IMNCI ANC(ante-natal care) HBNBC(home based new born care) BCC(behavior change communication) 75

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