integrated management of neonatal and childhood illnesses, Dr KRB

ppt for teaching purposes of medicine undergrads

1. 1 Integrated Management of Neonatal and Childhood Illness (IMNCI)

2. Plan of presentation 2 Background for IMCI Rationale for IMNCI IMNCI - Guidelines - Components - Principles of Integrated care - Elements of case management process - Case management process chart book F-IMNCI Implementation of IMNCI Critical review References

3. 3 IMR Of the world 34.9deaths/1000 live births India 43.8deaths/1000 live births U5MR Of the world 47.8deaths/1000 live births India 56.3deaths/1000 live births Reduce infant and child mortality rates Improving child health & survival IMR reduced from 114 (1980) to 47 ( 2010 SRS bulletin ) and now as above. Decline not uniform across states (worldbank.org data 2012-13) Introduction

4. Background of IMCI 4 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, diarrhoea , 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.

5. 5 Causes of Child deaths

6. Background of IMCI ( Contd …) 6 In India, common illnesses in children under 3 years of age include fever (27%), acute respiratory infections (17%), diarrhoea (13%) and malnutrition (43%) and often in combination. * 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. ** Many sick children are not properly assessed and treated by these health care providers, and that their parents are poorly advised. * National Family Health Survey- India, 1998-99 ** Global Burden of disease, WHO, Geneva, 1996

7. 7 Infant mortality trend in India

8. 8 Neonatal mortality in India

9. 9 IMR and MDG

10. Rationale for an integrated evidence based syndromic approach to case management 10 Many well-known prevention and treatment strategies have already proven effective for saving young lives. As each of these interventions has been successful, accumulating evidence suggests that an integrated approach is needed to manage sick children to achieve better outcomes. Child health programmes need to move beyond single diseases to address the overall health and well-being of the child. Many children present with overlapping signs and symptoms of diseases, a single diagnosis can be difficult, and may not be feasible or appropriate. This is especially true for first -level health facilities where examinations involve few instruments, negligible laboratory tests, and no X-ray. During the mid-1990s, WHO in collaboration with UNICEF and many other agencies, institutions and individuals, responded to this challenge by developing a strategy known as the Integrated Management of Childhood Illness (IMCI).

11. Key features of IMCI 11 IMCI is an integrated approach to child health that focuses on the well-being of the whole child. IMCI aims to reduce death, illness and disability and to promote improved growth and development among children under 5 years of age. IMCI strategy promotes the accurate identification of childhood illnesses in out patient settings. Ensures appropriate combined treatment of all illnesses.

12. Key features of IMCI (Contd. . .) 12 Strengthens the counseling of caretakers. Speeds up the referral of severely ill children. Promotes appropriate care seeking behaviors, improved nutrition & preventive care & correct implementation of prescribed care. Provision of home based newborn care to promote exclusive breastfeeding prevent hypothermia improve illness recognition & timely care seeking

13. 13 IMNCI- India Home visits for young infants: Schedule All newborns : 3 visits (within 24 hours of birth, day 3-4 and day 7-10) Newborns with low birth weight: 3 more visits on day 14, 21 and 28 .

14. IMCI Process: Source: IMCI; Student’s Handbook, WHO

15. IMNCI- India 15 Incorporation of neonatal care as it now constitutes two thirds of infant mortality. Inclusion of 0-7 days. Incorporating National guidelines on Malaria, Anemia, Vitamin A supplementation and Immunization schedule. Training begins with sick young infant up to 2 months. Proportion of training time devoted to sick young infant and sick child is almost equal. Skill based.

16. 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.)

17. 17

18. 18 Up to 50% of neonatal deaths are in the first 24 hours 75% of neonatal deaths are in the first week – 3 million deaths Time when most babies die is when coverage of care is lowest

19. Guidelines for IMNCI 19 Evidence-based, syndromic approach to case management that includes rational, effective and affordable use of drugs and diagnostic tools. Evidence - based medicine stresses the importance of evaluation of evidence from clinical research and cautions against the use of intuition, unsystematic clinical experience, and untested pathophysiologic reasoning for medical decision-making. In situations where laboratory support and clinical resources are limited, the syndromic approach is a more realistic and cost-effective way to manage patients.

20. 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. 20

21. Components of IMNCI strategy 21 Improvements in the case-management skills of health staff through the provision of locally-adapted guidelines on Integrated Management of Neonatal and Childhood Illness and activities to promote their use. Improvements in the overall health system required for effective management of neonatal and childhood illness. Improvements in family and community health care practices.

22. 22

23. Principles of integrated care 23 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.

24. Principles of integrated care (Contd. .) 24 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. Only a limited number of carefully selected clinical signs are used, based on evidence of their sensitivity and specificity to detect disease. A combination of individual signs leads to a child's classification(s) rather than diagnosis. Classification indicate the severity of conditions

25. Principles of integrated care (Contd. .) 25 They call for specific actions based on whether the child Use of limited number of essential drugs and encourage active participation of caretakers in the treatment of infants and children. - 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)

26. IMNCI is a Key Strategy for Improving Child Health B y integration Nutrition Immunization Other disease prevention Promotion of growth and development Management of sick children Integrated Management of Childhood Illness

27. Elements of case management process 27 Assess - Child by checking for danger signs. 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.

28. 28 The case management process…

29. 29 IMCI case management at first level health facility, referral level, and home :

30. Integrated Case Management Process for the sick young infant up to 2 months of age 30

31. Assess , classify and treat the sick young infant up to 2 months 31

32. 32 Look … listen… feel…

33. Assess and classify young infant for diarrhoea 33

34. Feeding problem and malnutrition chart 34

35. 35 Treatment of sick young infants

36. 36

37. 37

38. Counseling a mother or caretaker 38 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

39. Mother’s card 39

40. 40 Prescription slip

41. Integrated Case Management Process of children age 2 months up to 5 years 41

42. 42

43. 43

44. 44 Cough or difficult breathing

45. 45 Diarrhoea

46. 46 Malaria & Measles

47. Ear problem chart 47

48. Malnutrition chart 48

49. 49

50. Anaemia chart 50

51. 51 Treatment procedures for sick children

52. 52

53. Facility based -IMNCI 53 Acute shortage of Pediatricians in the country; as against the required number of 4045 there are only 898 paediatricians in position. * The introduction of F-IMNCI will help build capacities of the health personnel at facilities to address new born and child hood illness and thus help bridge this acute shortage of specialists. * Bulletin on Rural Health Statistics 2007

54. F-IMNCI 54 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 The integrated approach of IMNCI and Facility based care; (F-IMNCI) therefore provides a continuum of quality care for severely ill newborns and children from the community and to the facility. Majority of the health facilities (24x7 PHCs, FRUs, CHCs and District hospitals) do not have trained pediatricians 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.

55. Components of F-IMNCI 55 Skill based training Improvements to the health system : Logistics/Manpower/ Referral mechanisms Improvement of Family and Community Practices

56. Institutional arrangements 56 State level District level Trainee: Trainers: Training of trainers: Number to be trained: Training institutions: Funding :

57. 57 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. Evidence that 80% of deaths of children under five years of age occur at home with little or no contact with health providers. ( Kirk et al.) 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.

58. 58 16 key family practices identified Under Four Broad Heading: The promotion of growth and development of the child: Exclusive Breastfeeding for six months. Good quality complementary foods after six months. Continue breastfeeding for two years or longer. Ensure enough micronutrients – such as vitamin A, iron and zinc – in diet or through supplements.  Promote mental and social development by responding to a child’s needs for care and by playing, talking and providing a stimulating environment.   Disease prevention: Dispose of all faeces safely, wash hands after defecation, before preparing meals and before feeding children. Protect children in malaria endemic areas, by ensuring that they sleep under Insecticide - treated bed nets. Provide appropriate care for HIV/AIDS affected people, especially orphans, and Take action to prevent further HIV infections. C - IMNCI : cont.…

59. 59 C - IMNCI: cont.… Appropriate care at home: Continue to feed and offer more fluids, including breast milk to children when they are sick. Appropriate home treatment for infections. Protect children from injury and accident and provide treatment when necessary. Prevent child abuse and neglect, and take action when it does occur. Involve fathers in the care of their children and in the reproductive health of the family. Care-seeking outside the home: Recognize when sick children need treatment outside the home and seek care from appropriate providers.  Complete a full course of immunization before first birthday. Follow the health provider’s advice on treatment, follow-up and referral.  Ensure that every pregnant woman has adequate antenatal care, and seeks care at the time of delivery and afterwards.

60. 60

61. Inadequacies in Health system: Health worker skills: Incomplete examinations and counselling. Poor communication between health workers and parents. Irrational use of drugs. Health system issues: - Access to health services and Scarce availability of Skilled Worker - Availability of appropriate drugs and vaccines - Supervision / organization of work Community and family practices: Delayed care seeking Poor knowledge of when to return to a health facility Seeking assistance from unqualified providers Poor adherence to health worker advice and treatment

62. Implementation of IMNCI in India/Karnataka 62 As of December 2009, about 297 districts are implementing this programme in India. In Karnataka, IMNCI programme is implemented in Raichur district as a pilot project during 2005-06. Till date 14 districts have been covered with an objective to cover all the districts of the state by 2011-12 in Karnataka.

63. Strengths of IMNCI 63 Evidence based management decisions. Feasible to incorporate into both pre-service training & in-service training. Hands-on clinical training for 50% of training time. Focus on communication & counselling skills. Locally adapted recommendations for infant and young child feeding. Cost effective. Lowers the burden to hospitals. Model to improve health care.

64. Challenges of IMNCI 64 Issues regard to safe home delivery. A referral system with linkages between the different health care systems. Care of newborn at birth and childhood injuries. Feasibility of provision of health care using IMNCI at sub- center and village level by ANMs and AWWs. Irregular supply of drugs & logistics. Lack of proper supervision. Making home based care of young infants operational by ANMs and AWWs and a high staff turnover.

65. References 65 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.

66. 66

67. 67 IMNCI …In an effort to meet Millennium Goals