IMCIGroup 1 BSN 3-A Brgy. Manduyog, Alimodian, Iloilo Integrated Management of Childhood Illness (IMCI) Background Every day, millions of parents seek health care for their sick children, taking them to hospitals, health centres, pharmacists, doctors and traditional healers. Surveys reveal that many sick children are not properly assessed and treated by these health care providers, and that their parents are poorly advised. At first-level health facilities in low-income countries, diagnostic supports such as radiology and laboratory services are minimal or non-existent, and drugs and equipment are often scarce. Limited supplies and equipment, combined with an irregular flow of patients, leave doctors at this level with few opportunities to practice complicated clinical procedures. Instead, they often rely on history and signs and symptoms to determine a course of management that makes the best use of the available resources. These factors make providing quality care to sick children a serious challenge. WHO and UNICEF have addressed this challenge by developing a strategy called the Integrated Management of Childhood Illness (IMCI). What is IMCI? 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 five years of age. IMCI 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: y y y Improving case management skills of health-care staff Improving overall health systems Improving family and community health practices. In health facilities, the IMCI strategy promotes the accurate identification of childhood illnesses in outpatient settings, ensures appropriate combined treatment of all major illnesses, strengthens the counselling of caretakers, and speeds up the referral of severely ill children. In the home setting, it promotes appropriate care seeking behaviours, improved nutrition and preventative care, and the correct implementation of prescribed care. Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit 1 IMCI has already been introduced in more than 75 countries around the world. Peru. cost and effectiveness of the IMCI strategy. and for getting children to clinics or hospitals when needed. which takes into account the variety of factors that put children at serious risk. To date. Manduyog. Adapting the standard IMCI clinical guidelines to the country·s needs. Developing support mechanisms within communities for preventing disease. MCE has been conducted in Brazil. Uganda and the United Republic of Tanzania. Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit 2 . emphasizing prevention of disease through immunization and improved nutrition. IMCI is an integrated strategy. How is IMCI implemented? Introducing and implementing the IMCI strategy in a country is a phased process that requires a great deal of coordination among existing health programmes and services. Alimodian. Upgrading care in local clinics by training health workers in new methods to examine and treat children. Iloilo Why is IMCI better than single-condition approaches? Children brought for medical treatment in the developing world are often suffering from more than one condition. available drugs. and by national and international partners in development. It involves working closely with local governments and ministries of health to plan and adapt the principles of the approach to local circumstances.IMCI Group 1 BSN 3-A Brgy. making a single diagnosis impossible. The main steps are: y y y y y y Adopting an integrated approach to child health and development in the national health policy. for helping families to care for sick children. and to the local foods and language used by the population. Strengthening care in hospitals for those children too sick to be treated in an outpatient clinic. Making upgraded care possible by ensuring that enough of the right low-cost medicines and simple equipment are available. policies. What has been done to evaluate the IMCI strategy? CAH has undertaken a Multi-Country Evaluation (MCE) to evaluate the impact. The results of the MCE support planning and advocacy for child health interventions by ministries of health in developing countries. Bangladesh. It ensures the combined treatment of the major childhood illnesses. and to effectively counsel parents. Iloilo The results of the MCE indicate that: y y y y y y IMCI improves health worker performance and their quality of care. Determine which age group the child belongs: 1 week up to 2 months 2 months up to 5 years 2.if the child·s condition improved. Record the child·s data : Name.the child has been seen a few days ago for the same illness . Determine if this is an initial or follow ² up visit: Initial visit ² 1st visit for this episode of an illness or problem Follow-up visit. Steps in the IMCI Case Management Process: 1. Assess and Classify Sick Children 2 months up to 5 Years 1. Ask the mother what the child·s problems are. a significant reduction in under-five mortality will not be attained unless large-scale intervention coverage is achieved. if implemented well. 4. etc. Alimodian. Manduyog. 5. 3. temperature. 2.. IMCI is worth the investment. the implementation of child survival interventions needs to be complemented by activities that strengthen system support. 4. IMCI can reduce under-five mortality and improve nutritional status. not able to drink or breastfeed y too weak to drink and is not able to suck or swallow when offered a drink or Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit 3 . Age in months. Assess and Classify Identify Treatment Treat Counsel the Mother Follow-Up A. Weight in kg. still the same or is getting better 4. child survival programmes require more attention to activities that improve family and community behaviour. Check for general danger signs: a. as it costs up to six times less per child correctly managed than current care. 3.IMCI Group 1 BSN 3-A Brgy. y how long? Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit 4 . If the nose is blocked. fast breathing ² body·s response to stiff lungs and hypoxia 2. Iloilo Breast-feed y if not sure: ask mother to offer child a drink of clean water or breast milk y A child may have difficulty sucking when his nose is blocked.IMCI Group 1 BSN 3-A Brgy. 5. offer the child water c. b. complete the assessment and any pre-referral treatment immediately so referral is not delayed. count the number of breaths first before you try to wake the child. Manduyog. hypoxia ² too little oxygen 2. 2. Stretococcus pnemoniae 2. shaken or spoken to Note: 1. vomits everything y a child is not able to hold anything down at all y if in doubt. even if eyes are open y ´fitsµ or ´spasmsµ or ´jerky movementsµ Note: Shiver is not convulsion. If there is any general danger sign. clean it. d. If the child is asleep and has cough or difficult breathing. chest indrawing Assess cough or difficult breathing: Does the child have cough or difficult breathing? ´fastµ or ´noisyµ or ´interruptedµ? * If the answer is NO. convulsions (during this illness) y arms and legs stiffen because muscles are contracting y the child may lose consciousness or not be able to respond to spoken directions or handling. abnormally sleepy or difficult to awaken y drowsy and does not show interest in what is happening around him y stare blankly and appear no to notice what is going on around him y does not respond when touched. Assess and classify cough or difficult breathing y 2 Common Causes of Pneumonia 1. sepsis ² generalized infection y Health workers can identify almost all causes of pneumonia by checking for 2 clinical signs: 1. look back to see if you think the child has cough or difficult breathing. Hemophilus influenzae y 2 Causes of Death 1. Alimodian. There is no loss of consciousness. Iloilo y chronic cough ² more than 30 days .may be sign of tuberculosis. Assess and classify diarrhea diarrhea ² loose or watery stool .defined as 3 or more loose or watery stools in a 24 ² hour period Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit 5 . repeat the count. no feeding. crying or angry Ask the mother to lift the child·s shirt. or epiglottis Put your ear near the child·s mouth and look at the movement of the abdomen to determine if child is breathing IN or OUT wet noise . trachea. count the breaths in one minute 1.harsh noise while breathing OUT. not stridor CLASSIFY COUGH OR DIFFICULT BREATHING 6. Manduyog.blocked nose wheezing .happens when there is swelling of the larynx. y Look or listen for stridor. Stridor ² harsh noise made when the child breaths IN . If you are not sure about the number of breaths you counted. whooping cough or another problem fast breathing a. asthma. cut-off for fast breathing: if the child is: 2 months up to 12 months more 12 months up to 5 years more fast breathing is: 50 breaths/ minute 40 breaths/ minute or or y Determine if the child is breathing IN or breathing OUT chest indrawing ² the lower chest wall goes IN when the child breaths IN NORMAL: the whole chest wall and abdomen move OUT when the child breaths IN Best position : lying down Conditions : clearly visible Note: intercostals indrawing or intercostals retractions and subcostal indrawing are not chest indrawing. b. Alimodian. child must be quiet and calm 2.IMCI Group 1 BSN 3-A Brgy. : DEHYDRATION PERSISTENT DIARRHEA DYSENTERY 7. ask the mother if the child·s eyes look unusual. y Pinch the skin of the abdomen: Goes back very slowly ² longer than 2 seconds Goes back slowly ² the skin stays up for even a brief time after release.the child has an axillary temperature of 37. CLASSIFY DIARRHEA FOR .IMCI Group 1 BSN 3-A Brgy. y Offer the child fluid : Not able to drink . Assess Fever: A child has the main symptom fever if: . asses for: y dehydration y persistent diarrhea ² 14 days or more y Dysentery Asses for dehydration: y Abnormally sleepy or difficult to awaken y Restless and irritable: (all the time) y Sunken eyes: If not sure. Look or feel for stiff neck: . Drinking eagerly.if he is not able to take fluid in his mouth and swallow it Drinking poorly ² if the child is weak and cannot drink without help. Manduyog.the child has history of fever ² no fever now but had fever within 72 hours or .look to see if the child moves and bends his neck easily as he looks around or . Iloilo Assess: y how long? y blood in stool y signs of dehydration If YES.the child feels hot or . thirsty ² reaches out for the cup or spoon when you offer water. Alimodian.draw the child·s attention to his toes or Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit 6 .5 C or above Decide malaria risk: child lives in malarious area or has been in a malaria risk area in the past 4 weeks. bleeding from the nose and gums .Ear discharge .Perform the tourniquet test if: there are no signs in the ASK or LOOK and FEEL.IMCI - Group 1 BSN 3-A Brgy. CLASSIFY FEVER 8. or red eyes. Check for malnutrition and anemia: Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit 7 .Tender swelling behind the ear CLASSIFY EAR PROBLEM 9.Look and feel for signs of bleeding and shock: . Assess Ear Problem Assess the child for : . does not have vesicles or pustules.If with cold and clammy extremities. Manduyog.Ear pain . Look for runny nose ( not history of runny nose) Look for signs of Measles: generalized rash and any one of the following: cough. assess for: . and the fever is present for more than 3 days. check for slow capillary refill ( longer than 3 seconds .Cold and clammy extremities .skin petechiae ² small hemorrhages in the skin. not raised. . the child is 6 months or older. Alimodian. Iloilo gently support his back and bend the head forward toward hid chest. if you stretch the skin they do not lose their color. not tender. runny nose. and to the rest of the body.clouding of the cornea ² hazy area in the cornea Assess for Dengue Hemorrhagic Fever all children two months of age or older. If the child has measles now or within the last 3 months. look like small dark red spots or patches in the skin.pus draining from the eye . does not itch. Present less than 2 weeks ² Acute ear infection Present 2 weeks or more ² Chronic Ear Infection . Measles rash: begins behind the ears and on the neck. spreads to the face.mouth ulcers ² painful open sore on the inside of the mouth and lips or tongue . Look for nasal flaring ² widening of the nostrils when the young infant breaths in. Mild chest indrawing is normal in a young infant or young child. a form of severe malnutrition. 1. 2. Check the child·s Vitamin A status. Iloilo Look for visible severe wasting ² a child with visible severe wasting has marasmus. has no fat. Management of the Sick Young Infant Age 1 Week Up to 2 Months 1. 12. Ask if the child had convulsion at any time after birth. 3.IMCI Group 1 BSN 3-A Brgy. Determine weight for age: Very low weight for age ² child·s weight is below the bottom curve of a weight for age chart. Fast breathing is 60 breaths per minute or more. CLASSIFY NUTRITIONAL STATUS 10. Look for severe chest indrawing.. A child has this sign if he is thin. B. Assess the sick young infant Check the young infant for possible bacterial infection. 5. Assess other Problems. and looks like skin and bones. Look for palmar pallor ² a sign of anemia Some palmar pallor ² the skin on the child·s palm is pale Severe palmar pallor ² the palm is very pale or so pale that it looks white Look and feel for edema of both feet ² the child may have kwashiorkor. 11. Count the number of breaths in one minute. Severe chest indrawing is very deep and easy to see. Alimodian. short sounds when breathing out. 4. Manduyog. Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit 8 . Look and listen for grunting ² soft. Check the child·s immunization status. a form of severe malnutrition. rectal temperature 38 C or more). Is it ´Abnormally sleepy or difficult to awakenµ or ´Restless and irritableµ? Look for sunken eyes. with infant·s nose opposite her nipples . Assess Breastfeeding. LOOK: See if the child is abnormally sleepy or difficult to awaken.Mouth wide open . Are they less that normal? CLASSIFY ALL SICK YOUNG INFANT FOR BACTERIAL INFECTION Assess Diarrhea For how long? Is there blood in the stool? Look at the young infant·s general condition. A severe pustule is large of has redness extending beyond the pustule. Iloilo 6. Manduyog.with infant·s body close to her body .Chin touching breast . not just neck and shoulders 4 Sign of Good Attachment: .5 C. 7.supporting infant·s whole body. ¶Look and feel for bulging fontanelle.with infant·s head and body straight . 10.IMCI Group 1 BSN 3-A Brgy. Look for skin pustules ² red spots or blisters which contain pus. Pinch the skin of the abdomen. Does it go back very slowly? Or slowly? CLASSIFY DIARRHEA Check for feeding problem or low weight. Hypothermia ( axillary temperature below 35. Fever (axillary temperature 37. 9. Measure temperature or feel for fever or low body temperature. 11. Fontanelle is the soft spot on the top of the young infant·s head. LOOK at the young infant·s movement. . Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit 9 . rectal temperature below 36 C). where the bones of the head have not formed completely.Lower lip turned outward . 4 Signs of Good Positioning. Look at the umbilicus ² is it red or draining pus? 8.5 C or more.More areola visible above than below the mouth. Alimodian.facing her breast. html http://www.int/child_adolescent_health/topics/prevention_care/child/imci/en /index. You may see or hear the infant swallowing. Thrush looks like milk cuds on the inside of the cheek.IMCI Group 1 BSN 3-A Brgy. Alimodian. Milk curds will be removed but thrush will remain. Check the Young Infant·s Immunization Status Assess Other Problems REFERENCES: http://www. Look for ulcers or white patches in the mouth (thrush). Not suckling at all ² not able to suck breastmilk into his mouth and swallow.who. shallow sucks. Iloilo Suckling effectively ² the infant suckles with slow.com/doc/2224624/Handouts-IMCI Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit 10 . Try to wipe it off. Not suckling effectively ² he is taking only rapid. You may see indrawing of the cheeks. Manduyog.scribd. deep sucks and sometimes pauses. You do not see or hear swallowing. or thick white coating of the tongue.