Latest IMNCI presentation on the child and neonatal health care delivery.

Care of the new born, disease prevention and health promotion

1. INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS BY

2. OUTLINE Definition Why IMNCI Overview Goal of IMNCI Steps of Management Process IMNCI Case Categories Component of IMNCI Principles of IMNCI Case Management

3. DEFINITION Integrated management of neonatal and childhood illness (IMNCI) is a strategy that integrates all available measures for health promotion, prevention and integrated management of childhood diseases through their early detection and effective treatment, and promotion of healthy habits within the family and community.

4. DEFINITION cont. IMNCI is an integrated approach to child health that focuses on the wellbeing of the whole child and primarily on that most causes of child mortality. E.g. Diarrhoea , pneumonia, measles, malaria, and malnutrition , from age 0 - 5years It includes both preventive and curative measures to be implemented by families and communities as well as by health facilities.

5. WHY IMNCI An integrated approach is needed to manage sick children to achieve better outcomes. Child health programmes need to move beyond tackling single diseases in order to address the overall health and well-being of the child. Emphasis prevention of diseases of through immunization and improved nutrition. First level facilities do not have many diagnostic tools to provide quality care to sick children. universal immunization essential newborn care, exclusive breastfeeding during the first 6months of life, appropriate complementary feeding ORT and timely appropriate use of antibiotic in pneumonia treatment have proven to be effective.

6. OVERVIEW Every year more than 10 million children die in developing countries before the age of 5, (WHO 2003). 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.

7. Under 5 Causes of Death

8. Overview cont. Almost 19,000 children under 5 years of age died everyday across the world. 50% of it occurs in just five countries i.e. India, Nigeria, Congo, Pakistan and China. 5.4 million children under age 5 died in 2017, (WHO, GHO data) . The risk of a child dying before completing five years of age is still highest in WHO African Region (74 per 1000 live births), around 8 times higher than that in the WHO European Region (9 per 1000 live births).

9. Overview cont. Many countries still have very high under-five mortality – particularly those in WHO African Region, in which Nigeria is one, home to 5 of the 6 countries with an under-five mortality rate above 100 deaths per 1000 live births. Globally, under-five mortality rate has decreased by 58%, from an estimated rate of 93 deaths per 1000 live births in 1990 to 39 deaths per 1000 live births in 2017. This is equivalent to 1 in 11 children dying before reaching age 5 in 1990, compared to 1 in 26 in 2017.

10. Overview cont. The end of MDG era, ushered in the Sustainable Development Goals (SDGs) which target is to end preventable deaths of newborns and children under 5 years of age. The goal is for all countries is to reduce under-five mortality to at least as low as 25 per 1000 live births. 117 Member States already met the SDG target on under-five mortality, 26 countries are expected to meet the target by 2030, if current trends continue.

11. Goals of IMNCI Standardized case management of sick newborns and children. Focus on the most common causes of mortality Nutrition assessment and counseling for all sick infants and children. Home care for new born to promote exclusive breastfeeding prevent hypothermia, improve illness recognition and timely care seeking.

12. Steps/Elements of case management process Assess child by checking for danger signs by history and examined Classify child’s illness by colour coded triage system ( Pink – Give pre referral treatment and refer ugently to hospital, Yellow- give specific medical treatment and advice as done in OPD or Clinic, and Green- home management / safe remedy Identify specific treatments Treatments instructions on oral drugs, feeding fluids. Counsel mothers on breast feeding, her own health as well as to follow further instructions on further childcare. Follow up care, reassess the child for improvement or new problems

13. Case Management Categories There are two age categories; Young infant (0 - 2 months), 2 months - 5 years.

14. Components of IMNCI IMNCI strategy includes three main components: Improvement of case management skills of healthcare provider through locally adapted guidelines. Improvement in the overall health systems required for management. Improvements of family and community health practices.

15. IMNCI Strategy for Healthcare Givers The clinical guidelines designed for the management of age 0-5 by healthcare providers includes: Assessing a child’s nutrition, immunization and feeding. Teaching parents how to care for a child at home. Counselling parents to solve feeding problems. Checking the parents’ understanding of the advice given and showing them how to administer the first dose of treatment. Advising parents about when to return to a health facility.

16. IMNCI Strategies in Health Facility The purpose of IMNCI in health centres is to: Promote the accurate identification of childhood illnesses in out-patient settings. Quality improvement and supervision at health facilities Ensure appropriate combined treatment of all major illnesses / availability of IMNCI drugs. Strengthen the counselling of caregivers. Speeds up the referral of severely ill children.

17. Principles of IMNCI in Health Facility All sick young infants up to 2 months of age must be assessed for possible bacteria/infections/jaundice and major symptoms diarrhoea . All sick children age 2 months up to 5 years must be examined for general danger signs. They must be routinely assessed for major symptom: cough or difficult breathing, diarrhea, fever and ear problems.

18. Principles of IMNCI in Health Facility cont. Every child must be routinely assessed for nutritional and immunization status, feeding problems and other potential problems. IMNCI uses a limited number of essential drugs and encourage active participation of caretakers in the treatment. IMNCI addresses most, but not all, of the major reasons a sick child is brought to a clinic. One of the essential component of IMNCI is the counseling of caregivers and home care, feeding, fluids and when to returns to health facility.

19. 5 General Danger Signs Inability to drink or breastfeed, Vomiting everything, History of convulsions during the current illness, Lethargy or unconsciousness and Convulsions now. A child with any general danger sign should be referred urgently after receiving urgent pre-referral treatment .

20. Steps to Take When to Treat a Sick Child Assessment Classification, Identify Treatment Treat the child Follow-up Care Counsel mother.

21. Strategies of IMNCI in Home Setting Promotes appropriate care-seeking behaviours Helps to improve nutrition and preventative care, Supports the correct implementation of prescribed care. Encourages case management adherence to recommended treatment.

22. IMNCI case Management of a Child in Health Facility IMNCI uses series of charts which show the sequence of steps to take in providing care and at the same time providing information for performing them. The charts help to: Assess the young infant, child and mother Classify the illness Identify the treatment Treat the child Counsel the mother/ caregiver Give follow up care

23. Management of Young Infant age -2 months Assessment (Look, Listen and Feel) Ask the mother what the young infant’s problems are. Assess the infant for : 5 General Danger Signs (GDS) From head to toes, Jaundice, bacterial infection- cord, fontanelle , ear, skin, Diarrhoea , feeding problem, low weight, take Immunization history Mother’s health

24. Management of Young Infant age -2 months cont. Identify problems CHECK FOR POSSIBLE BACTERIAL INFECTION / JAUNDICE Classify problems Ask, Look, Feel 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 the umbilicus. Is it red or draining pus? Look for skin pustules. Are there 10 or more pustules or a big boil? Check temperature ( feel for fever or low body temperature): See if young infant is lethargic or unconscious Look at young infant’s movements. Less than normal? Look for jaundice. Are the palms and soles yellow? Eg Local bacterial infection Pneumonia etc

25. Management of Young Infant age -2 months cont. Identify problems Classify problems DOES THE YOUNG INFANT HAVE DIARRHOEA? Yes ___ No ___ For how long? ____ Days Is there blood in the stool? Look at the young infant’s general condition. Is the infant: Lethargic or unconscious? Restless and irritable? Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly? Some Dehydration Severe dehydration etc

26. Management of Young Infant age -2 months cont. Identify problems Classify problems CHECK FOR FEEDING PROBLEM & MALNUTRITION Is there any difficulty feeding? Yes __ No _ Is the infant breastfed? Yes ___ No ___ If Yes, how many times in 24 hours? 6-7 times Does the infant usually receive any other foods or drinks? Yes ___ No ____ If Yes, how often? What do you use to feed the infant? Determine weight for age. Very low ___ Low __ Not Low ___ 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: Feeding problem Or Low weight

27. Management of Young Infant age 0-2 months Cont. Classification of Diarrhoea Treatment Severe dehydration( Lethargic, unconscious, sunken eyes) If there is no PSBI, give fluid for severe dehydration, If there is PSBI, refer immediately, with mother giving ORS and breastfeeding Some dehydration Give fluid, food, If there is PSBI, refer immediately, with mother giving ORS and breastfeeding No dehydration Give fluid and food Home care, breastfeeding Diarrhoea lasting 14 days or more If dehydrated, treat before you refer unless there is PSBI Dysentery Give ist dose of appropriate Antibiotics Urgently refer.

28. Management of Young Infant age 0 -2 months Cont. Classification Treatment Feeding problem/ low weight Advise as appropriate If not breastfeeding at all, refer for counselling , relactation , infant meal substitute using cup and spoon, home care Follow up in 2 days No Feeding problem/ low weight Advise on home care Breastfeeding counselling

29. Management of Young Infant age 0-2 months Cont. Check immunization schedule; according to age, to see if necessary vaccines have been given. Assess other problem. Counsel mother on her own health If sick, provide care, if there is breast problem, e.g. nipple , engorgement, sore Advise on good feeding, proper hygiene, family planning, prevention/ treatment of STI/AIDS prevention

30. OTHER HEALTH PROBLEMS Ear problems Fever etc

31. REFERRAL OF YOUNG INFANTS UP TO 2 MONTHS OF AGE All infants and children with a severe classification (pink) are referred to a hospital as soon as assessment is completed and necessary pre-referral treatment is administered. Give urgent pre-referral treatment(s). Which may include: First dose of intramuscular or oral antibiotics Keeping the infant warm on the way to the hospital Prevention of hypoglycemia with breastmilk or sugar water Frequent sips of ORS solution on the way to the hospital

32. Referral Note Name and age of the infant; 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 infant, such as earlier treatment of the illness or any immunizations needed.

33. Follow up visit Advise when to return A) IMMEDIATELY Advise to return immediately if the infant has any of these signs: Breastfeeding or drinking poorly Becomes sicker Develops a fever or feels cold to touch Fast breathing Difficult breathing Yellow palms and soles (if young infant has jaundice) Diarrhoea with blood in stool

34. Management of Child 2 Months- 5 Years Condition included in the charts Cough Diarrhoea Fever; malaria, measles, Ear discharge Malnutrition Anaemia HIV infections Recommended immunization and other health problems

35. CASE STUDY 1 Fatima is 18 months old. She weighs 11.5 kg. Her temperature is 37.5 C. The physician asked, "What are the child's problems?" The mother said "Fatima has been coughing for 6 days, and she is having trouble breathing." This is the initial visit for this illness. The physician checked Fatima for general danger signs. The mother said that Fatima is able to drink. She has not been vomiting. She has not had convulsions during this illness. The physician asked, "Does Fatima seem unusually sleepy?" The mother said, "Yes." The physician clapped his hands. He asked the mother to shake the child. Fatima opened her eyes, but did not look around. The physician talked to Fatima, but she did not watch his face. She stared blankly and appeared not to notice what was going on around her. Is any of the general danger signs present?

36. Case study 1 cont. The physician asked the mother to lift Fatima's shirt. He then counted the number of breaths the child took in a minute. He counted 41 breaths per minute. The physician did not see any chest indrawing . He did not hear stridor. The physician asked, "Does the child have diarrhoea ?" The mother said, "Yes, for 3 days.“ There was no blood in the stool. Fatima's eyes looked sunken. The physician asked, "Do you notice anything different about Fatima's eyes?" The mother said, "Yes." He gave the mother some clean water in a cup and asked her to offer it to Fatima. When offered the cup, Fatima would not drink. When pinched, the skin of Fatima's abdomen went back slowly.

37. Case study 1 cont. Child's Name: Domino ________________ Age: 18 months Weight: 11.5 kg Temperature: 37.5 C A ASK: What are the child's problems? cough, trouble breathing, Initial Visit? ___ Follow-up Visit?__ ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS General danger sign present? NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS Yes --- No --- VOMITS EVERYTHING CONVULSIONS

38. Case study 1 cont. The physician asked the mother to lift Fatima's shirt. He then counted the number of breaths the child took in a minute. He counted 41 breaths per minute. The physician did not see any chest indrawing . He did not hear stridor. Fast breathing PNEUMONIA No signs of pneumonia or very severe disease NO PNEUMONIA: COUGH OR COLD

39. Case study 1 cont. MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS Child's Name: Fatima Age: 18 months Weight: 11.5 kg Temperature: 37.5 C ASK: What are the child's problems? cough, trouble breathing Initial Visit? ASSESS (Circle all signs present) CLASSIFY CHECK FOR GENERAL DANGER SIGNS General danger sign present? NOT ABLE TO DRINK OR BREASTFEED LETHARGIC OR UNCONSCIOUS Yes 􀀹 No ___ VOMITS EVERYTHING Remember to use danger sign CONVULSIONS when selecting classifications

40. Case study 1 cont. DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes ___ No__ For how long? 6 Days Count the breaths in one minute. Severe Pneumonia 41 breaths per minute. Fast breathing Or Very Severe Look for chest indrawing . Disease Look and listen for stridor.

41. Case study cont. Because Fatima's temperature is 37.5 C and she feels hot, the physician assessed Fatima further for signs related to fever. The mother said Fatima's fever began 2 days ago. The risk of malaria is low. Fatima has not had measles within the last 3 months, and there are no signs suggesting measles. She does not have stiff neck. The physician noticed that Fatima has a runny nose.

42. CASE STUDY 2 Amit is 9 months old. He weighs 7 kg. His temperature is 36.8 C. He is at the clinic today because his mother and father are concerned about his diarrhoea . He does not have any general danger signs. He does not have cough or difficult breathing. He has had diarrhoea for 5 days, and is classified as diarrhoea with SOME DEHYDRATION. He does not have fever. He does not have an ear problem. Amit does not have signs of severe malnutrition or very low weight for age. Next, the physician checked for signs of anaemia .

43. Case Study 2 cont. URGENT PRE-REFERRAL TREATMENTS FOR THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS CLASSIFICATION TREATMENT DANGER SIGN If the child is convulsing, give diazepam (10 mg/2 ml solution) in dose 0.2 mg per kg (0.05 ml/kg) IV or rectally; if convulsions continue after 10 minutes, give a second dose of diazepam. CONVULSIONS

44. Summary on Management of Child 2 Months- 5 Years Cont. Assess the illness Classify the illness according to severity Identify treatment, Treat or refer as appropriate Check mother’s own health and treat as appropriate Advise on home care; feeding, giving of oral dugs, ORS preparation etc. Follow Up

45. Case Study ASSESSMENT OF SICK CHILDREN The assessment procedure for this age group includes a number of important steps that must be taken by the health care provider, including: History taking and communicating with the caretaker about the child’s problem; Checking for general danger signs; Checking main symptoms; Checking for malnutrition; Checking for anaemia ; Assessing the child’s feeding; Checking immunization status; Assessing other problems.

46. COUNSELLING A MOTHER OR CARETAKER USE GOOD COMMUNICATION SKILLS It is important to have good communication with the infant’s mother or caretaker from the beginning of the visit. Ask and Listen to find out what the infant’s problems are and what the mother is already doing for the infant, to know what she is doing well, and what practices need to be changed.. Praise the mother for what she has done well. Advise her how to care for her infant at home, using the language she understands. Check the mother’s understanding.

47. Steps to teaching how to do a task 3 basic teaching steps: 1. Give information. 2. Show an example. 3. Let her practice. Give information: Explain to the mother how to do the task. Eg . ORS Show an example: Show how to do the task. For example, show the mother a packet of ORS and how to mix the right amount of water with ORS Let her practice: Ask the mother to do the task while you watch. to know what she understands and what is difficult..

48. QUESTIONING TECHNIQUE GOOD CHECKING QUESTIONS POOR CHECKING 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 the ointment? Have you used ointment on your child before? How much extra fluid will you give after each loose stool? Do you know how to give extra fluids? Why is it important for you to wash your hands? Will you remember to wash your hands?

49. FOLLOW-UP CARE IMMEDIATELY Advise to return immediately if the child has any of these signs. Not able to drink or drink or breastfeed Becomes sicker Develops a fever If child has no PNEUMONIA: COUGH OR COLD, also return if: Fast breathing Difficult breathing If child has diarrhoea , also return if: Blood in stool Drinking poorly

50. Follow up visit cont. B) FOR FOLLOW-UP VISIT If the infant has: Return for follow-up not later than LOCAL BACTERIAL INFECTION 2 days JAUNDICE 2 days DIARRHOEA 2 days ANY FEEDING PROBLEM 2 days THRUSH 2 days LOW WEIGHT FOR AGE 14 days

51. NEXT WELL-CHILD VISIT Advise when to return for the next immunization according to immunization schedule.

52. COUNSEL THE MOTHER ABOUT HER OWN HEALTH The mother may need treatment or referral for her own health problems. If the mother is sick, provide care for her, or refer her for help. Advise her to eat well to keep up her own strength and health. Check the mother’s immunization status and give her tetanus toxoid if needed. Give the mother iron folic acid tablets if she is not already taken them. Make sure she has access to family planning and counselling on STD and AIDS prevention.

53. REFERENCES Adesokan , F.O. (2017), Essential Child Health Care, 1 st Edition, Ajaok Press, Ibadan. http://www.who.int/gho/child_health/mortality/mortality_under_five_tex t/en/ retrieved on 20 th Nov., 2018. Shubhanshu , G. (2014), Integrated management of neonatal and childhood illness Slideshare WHO, (2003), Student’s Handbook for Integrated management of neonatal and childhood illness WHO,. & UNICEF. (2008), Integrated management of neonatal and childhood illness, Dept.of Child and Adolescent Health and Development (CAH). WHO Press.