INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMCI)

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMCI)

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMCI)

Integrated Management of Childhood Illnesses is a child management process where care/treatment of a sick child is done in totality. The children managed under IMCI range from 1 week to 5 years.

IMCI aims at three (3) main components of health care.

  • Improving the health worker’s skill.
  • Improving the aspects of the health system.
  • Improving family and community practices.

Seventy five percent (75%) of deaths among children below five years in the developing world are usually due to:

  • Acute respiratory infection
  • Diarrhea diseases
  • Malaria
  • Malnutrition
  • Measles,
  • And more often one or a combination of these.

Millions of parents seek treatment for their children daily in the hospitals, health centers, clinics, traditional healers etc, but ¾ of these children suffer from the above diseases.

It is important to note that the above conditions, to a considerable degree have similar clinical presentations and therefore, there is common masked presentation that a health worker may overlook a potential life threatening situation.

Because of this overlap, a single diagnosis is often inappropriate in sick children.

The case management process

IMCI classifies children into two categories:

  • Sick young infants who range from 1 week to 2 months.

Less than 1 week infants are not managed under IMCI, mainly because their illnesses are usually related to antenatal, labour and delivery.

  • Sick child who range from 2 months to 5 years.

IMCI is designed for health workers (doctors, nurses etc) who treat sick children and infants in a first level health facility e.g. clinic, health center or OPD in hospital.

In the management process the following steps are taken:

  • Assessing the child/young infant.
  • Classify the illness.
  • Identify treatment.
  • Treating the child/ young infant.
  • Give counseling to the mother.
  • Give follow up care.
  • Assessing the child means taking the history and performing a physical examination.
  • Classify the illness implies making a decision on the severity of illness i.e. you select a category of classification which corresponds with the severity of the disease.

Note that, classifications are not specific diagnoses but can be used to determine treatment e.g. severe febrile disease is a classification for a child who could be having cerebral malaria, meningitis, septicemia etc, but treatment for this classification covers for all the possible causes of the problem.

Assessing and classification of a sick child

  • Determine whether this is an initial visit or a return (follow up) visit.
  • If it is an initial visit, Ask, “what is the child’s problem”?
  • After knowing the problem;
Check for general danger signs.

A general danger sign is an indicator that a child has a severe problem and therefore needs urgent referral.

General danger signs include:

  • The child is unable to drink/feed. This could be due to a situation where a child is too weak to drink. If the child has a blocked nose it may interfere with its ability to drink, therefore, ensure that its nose is not blocked.
  • Vomiting everything.
  • The child has convulsions.
  • The child is lethargic or unconscious.
  • Child is convulsing now.

Then ask about other main symptoms e.g

  • Does the child have a cough or difficult breathing?

If yes, ask:

How long?

Look, Listen and Feel.

  • Count the breaths in one minute.
  • Look for chest in-drawing.
  • Look and listen for a stridor or wheezing.

If the child has had two or more episodes of cough associated with fast or difficult breathing in the past three months, it is called recurrent pneumonia.

Note: The child must be calm.

Classify for cough

Signs

Classification

Treatment

Any general danger sign or chest in-drawing or stridor

Severe pneumonia or very severe disease

  • Give first dose of an appropriate antibiotic IM
  • If wheezing give a trial of rapid acting bronchodilator for up to 3 X before classifying severe Pneumonia.
  • Refer urgently to hospital.
  • Fast breathing: 2 months to one year, 50 or more breaths per minute.
  • 1-5 years, 40 or more breaths per minute.
  • Less than 2 months, 60 or more breaths.

Pneumonia

  • Give oral antibiotic for 5 days
  • If wheezing give a trial of rapid acting bronchodilator for up to 3 times before classifying pneumonia. If wheezing give an inhaled bronchodilator for 5 days
  • If recurrent wheezing refer for assessment
  • Soothe the throat and relieve the cough with a safe remedy
  • Check for HIV infection
  • If coughing for more than 30 days refer for possible TB or asthma
  • Advise the mother when to return immediately
  • Follow up in 2 days
  • No signs of pneumonia or severe disease

No pneumonia:

Cough or cold.

  • If wheezing give treatment as above
  • If recurrent wheezing refer
  • Sooth the throat and relieve the cough
  • If coughing for more than 30 days refer for possible TB or asthma
  • Advise mother when to return immediately
  • Follow up in 5 days if not improving

Management of Fever

In IMCI a child is said to have fever either by history or if child feels hot or has a temperature of38.5 ◦c and above.

If the child has fever,

Ask;

  • For how long?
  • If for more than 7 days, ask if it has been present every day. Then,
  • Has the child had measles within the last 3 months?

Look and feel for:

  • Stiff neck
  • Running nose

Look for signs of measles:

  • Generalized skin rash
  • One of the following:
  • Running nose
  • Cough or red eyes.

If the child has measles now

Or within the last 3 months:

  • Look for mouth ulcers. Are they deep and extensive?
  • Look for pus draining from the eye.
  • Look for clouding of the cornea.

Classify fever (high malaria risk)

Signs

Classification

Treatment

Any general danger sign or stiff neck

Very severe febrile disease

  • Give quinine for severe malaria (1st dose)
  • Give 1st dose of appropriate antibiotic
  • Treat the child to prevent hypoglycemia
  • Give 1 dose ofparacetamol in clinic for fever
  • Refer urgently to hospital.

Fever (by history or feels hot or temperature 38.5◦c or above)

Malaria

  • Give oral co-artemether or other recommended antimalarial
  • Give 1 dose of paracetamol for fever
  • Advise mother when to return immediately
  • Follow up in 2 days if fever persists
  • If fever is present every day for more than 7 days, refer for assessment

Malaria risk

Any general danger sign or stiff neck

Very severe febrile disease

  • Give treatment for severe malaria (1st dose)
  • Give 1st dose of appropriate antibiotic
  • Treat the child to prevent hypoglycemia
  • Give 1 dose of paracet. in clinic for fever
  • Refer urgently to hospital.

No runny nose

No measles and

No other cause of fever

Malaria

  • Give oral co-artemether or other recommended antimalarial
  • Give 1 dose of paracetamol for fever
  • Advise mother when to return immediately
  • Follow up in 2 days if fever persists
  • If fever is present every day for more than 7 days, refer for assessment.

Runny nose PRESENT or measles PRESENT or other causes of fever PRESENT

Fever- malaria unlikely

  • Give 1 dose of paracetamol in clinic for high fever 38.5◦c or above
  • Advise mother when to return immediately
  • Follow up in 2 days if fever persists
  • If fever is present every day for more than 7 days, refer for assessment.

If measles now or within last 3 months,

Classify

  • Any general danger sign or
  • Clouding of cornea
  • Deep or extensive mouth ulcer

Severe complicated measles

  • Give vitamin A for treatment
  • Give 1st dose of an appropriate antibiotic
  • If clouding of cornea or pus draining from the eye, apply T.E.O
  • Refer urgently to hospital
  • Pus draining from the eye or
  • Mouth ulcer

Measles with eye or mouth complications

  • Give vitamin A for treatment
  • If pus draining from the eye, treat eye infection with T.E.O
  • If mouth ulcers, treat with gentian violet
  • Follow-up in 2 days

Measles now or within the last 3 months

measles

  • Give vitamin A for treatment

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 for pus draining from the ear.

Feel for tender swelling behind the ear.

Classify Ear problem

Tender swelling behind the ear

Mastoiditis

  • Give the 1st dose of appropriate antibiotic
  • Give the 1st 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 antibiotic for 5 days

Give pararcetamol for pain

Dry the ear by wicking

If ear discharge, check for HIV infection

Follow-up for 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.
  • Treat with topical quinolone ear drops for 2 weeks
  • Check for HIV infection.
  • Follow-up in 5 days

No ear pain and

No pus seen draining from the ear

No ear infection

No treatment

Management of Diarrhea

If the child has diarrhea

Ask:

  • For how long?
  • Is there blood in the stool?

Look and feel:

  • Look at the child’s general condition. Is the child:
  • Lethargic or unconscious?
  • Restless and irritable?
  • Look for sunken eyes
  • Offer the child fluid. 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?

Signs

Classify as

Treatment

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
  • Drinking eagerly, thirsty
  • Skin pinch goes back slowly

Some dehydration

  • Give fluid, Zinc supplements 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

Not enough signs to classify as some or severe dehydration

No dehydration

  • Give fluid, Zinc supplements and food to treat diarrhea at home (Plan A)
  • Advise mother when to return immediately.

If diarrhea for 14 days or more

Dehydration present

Severe persistent diarrhoea

Treat dehydration before referral unless the child has another severe classification

Refer to hospital

No dehydration

Persistent diarrhea

  • Check for HIV infection
  • Advise the mother on feeding a child who has persistent diarrhea
  • Give multivitamins and zinc for 14 days
  • Follow up for 5 days

If blood in stool

Blood in stool

Dysentery

  • Give Ciprofloxacin for 3 days
  • Follow up in 2 days

Management of Malnutrition

Children with malnutrition may present in various ways according to the nutritional

deficiency they have. But the most important indicators of malnutrition include:

  • Wasting
  • Low weight for age
  • Anemia and
  • Body swelling

In assessing the child for malnutrition, anemia should also be assessed and the following are the steps in assessment:

  • Look for visible severe wasting
  • Look for palmer pallor which may be severe or mold
  • Ask if the child is a sickler
  • Look for edema of both feet
  • Determine weight for age
  • For child aged 6 months or more

Determine if MUAC less than11cm

If MUAC less than 11cm, or edema, assess appetite

  • If age up to 6 months:
  • With visible severe wasting
  • Or edema of both feet
  • If age 6 months and above and:
  • MUAC less than11cm or edema of both feet
  • And poor appetite or pneumonia or persistent diarrhea or dysentery

Severe complicated malnutrition

  • Treat the child to prevent low sugar
  • Refer urgently to hospital.

If age 6 months or above and

  • MUAC less than11cm or edema of both feet
  • And some appetite

Severe uncomplicated malnutrition

  • Counsel the mother on how to feed a child with RUFT, if available, or refer to OPT or hospital
  • Check for HIV infection
  • Give mebendazole (if child aged 1 year or above), and 1st line oral antibiotic
  • Assess the child’s feeding advise mother when to return immediately
  • Follow-up in 7 days

Very low weight for age

Very low weight

  • Assess the child’s feeding and counsel the mother on feeding according feeding recommendations
  • Check for HIV infection
  • Advise mother when to return immediately
  • Follow-up in 30 days

Not very low weight for age

Not very low weight

  • If child is less than 2 years old, assess the child’s feeding according to the feeding recommendations

If feeding problem, follow-up in 5 days

Advise mother when to return immediately.

Check for Anemia

Look and feel:

Look for palmar pallor. Is it:

  • Severe palmar pallor?
  • Some palmar pallor?

Classify anemia

Severe palmar pallor

Severe anemia

Refer urgently to hospital

Some palmar pallor

anemia

  • Give iron
  • Give oral antimalarial if high malaria risk
  • Check for HIV infection
  • Give mebendazole if child is 1 year or older and has not had a dose in the previous 6 months
  • Advise mother when to return immediately
  • Follow-up in 14 days

No palmar pallor

No anemia

If child is less than 2 years old, assess the child’s feeding and counsel the mother on feeding according to the feeding recommendations

If feeding problems, follow-up in 5 days

RUTF – Ready-To-Use Therapeutic Food

OTP – Out Patient Therapeutic Feeding point.

Check for HIV Infection

All children found to have pneumonia, persistent diarrhea, ear discharge or very low weight for age (any of these features) and has no urgent need or indication for referral, should be assessed for symptomatic HIV infection. In assessment, ask:

  • If the child is known to have +HIV test
  • If mother is known to have +HIV test

Look and feel:

  • For oral thrush
  • Enlarged and palpable lymph nodes in more than 1 site (the neck, the arm pit and the groin)
  • Parotid enlargement

Classify for HIV

Signs

Classify

Identify Treatment

  • Positive HIV antibody test for child 18 months and above

Or

  • Positive HIV for virological test

Confirmed HIV infection

  • Treat, counsel and follow-up existing infections
  • Give cotrimoxazole prophylaxis
  • Give vitamin A supplements from 6 months of age every 6 months
  • Assess the child’s feeding and provide appropriate counseling to the mother
  • Refer for further assessment including HIV care/ ART
  • Follow-up in 14 days, then monthly for 3 months and then every 3 months or as per immunization schedule

One or both of the following:

  • Mother HIV positive and no test result for child

Or

  • Child less than 18 months with + antibody test

HIV exposed/

Possible HIV

  • Treat, counsel and follow-up existing infections
  • Give cotrimoxazole prophylaxis
  • Give vitamin A supplements from 6 months of age every 6 months
  • Assess the child’s feeding and provide appropriate counseling to the mother
  • Confirm HIV infection status of child as soon as possible with best available test
  • Follow-up in 14 days, then monthly for 3 months and then every 3 months or as per immunization schedule
  • 2 or more conditions

And

  • No test results for child or mother

Suspected symptomatic HIV infection

  • Treat, counsel and follow-up existing infections
  • Give cotrimoxazole prophylaxis
  • Give vitamin A supplements from 6 months of age every 6 months
  • Assess the child’s feeding and provide appropriate counseling to the mother
  • Test to confirm HIV infection
  • Refer for further assessment including HIV care/ ART

Follow-up in 14 days, then monthly for 3 months and then every 3 months or as per immunization schedule

  • Less than 2 conditions

and

  • No test result for child or mother

Symptomatic HIV infection unlikely

  • Treat, counsel and follow-up existing infections
  • Advise the mother about feeding and about own health
  • Encourage HIV testing

Negative HIV test in mother and not enough signs to classify as suspected symptomatic HIV infection

HIV infection unlikely

  • Treat, counsel and follow-up existing infections
  • Advise the mother about feeding and about own health

Checking for the immunization status.

If the child is not immunized, give immunization accordingly.

Check vitamin A status if the child is 6 months or more. Give Vit. A if the child has not received the drug previously.

Treat any other problems if there is no requirement or indication for urgent referral. E.g. prevent low blood glucose by encouraging the mother to breastfeed the child frequently if the child is able to suckle or express breast milk or breast milk substitutes e.g. cow milk. If neither of the above is available give 30-50mls of glucose water (20gms of sugar-4 level tea spoons in 200mls of plain water).

Feeding Recommendations during Sickness and Health

Children up to 6 months

  • They should breastfeed as often as the child wants (day and night), at least 8 times.
  • Do not give other feeds or fluids except if they are 4 months or more and appear angry even after breastfeeding or if child is not gaining weight adequately(1-2 times after breast feeding).

6 months up to 1 year

  • Breastfeeding as often as the child wants and give adequate servings of thick porridge, e.g. millet, soya, cassava with sugar and add milk or pounded g/nuts. Or

Mixture of mashed foods e.g. potatoes, matooke or rice mixed with fish, g/nuts or beans and add green vegetables.

  • In between these foods give a snack, e.g. an egg, banana or bread three times, if they are breast feeding, 5 times if they are not breast feeding.

1-2 years

Breastfeed as often as the child wants and give foods as in (b) above and give a

snack or family foods five times.

2 years or older

Give family foods three times each day with nutritious snacks in between these feeds at least twice a day.

Advise the mother to return in the following situations

If the child has

Return in (for follow-up)

Pneumonia, dysentery, malaria, if fever persists.

Measles with eye or mouth complications.

2 days

Persistent diarrhea

Acute ear infection

Chronic ear infection

Feeding problem

Any other illness not improving

5 days

Pallor

2 weeks

Very low weight for age

1 month

When the child has improved advise the mother when to return for immunization according to immunization schedule.

Advise the mother when to return immediately if the mother notices the following:

  • Any sick child who:
  • Is not able to drink or breastfeed.
  • Becomes sicker.
  • Develops fever.
  • If no pneumonia: cough or cold:

Bring back child immediately if the following appears:

  • Fast breathing
  • Difficulty in breathing
  • If the child has diarrhea, return immediately blood in stool is noticed or if breastfeeding or drinking poorly.

Counsel the mother about her own health as follows:

  • If mother is sick, provide care for her or refer for help.
  • If has breast problem, such as engorgement, sore nipples, breast infections, provide care or refer for help.
  • Advise mother to eat well and encourage to maintain her strength and health.
  • Check her immunization status. Give T.T if there is need.
  • Make sure she has access to:
  • Family planning
  • STD and AIDS prevention counseling.
  • Antenatal care

MANAGING A SICK INFANT AGE UP TO 2 MONTHS

The management of sick infants is more or less the same the management of older infants or children. It also includes assessing, classifying, treating, counseling the mother and follow-up.

Young infants have special characteristics which must be considered when classifying their illness. They can become sick and die very quickly from serious bacterial infection but which may manifest themselves through general signs e.g. reduced movements, fever or even hypothermia, failure to breastfeed etc.

To Assess and Classify the Sick Young Infant

In assessment of sick young infant, the following is considered:

  • Possible bacterial infection i.e. meningitis, pneumonia, septicaemia, pemhigus (staphylococcus skin infection) etc.
  • Diarrhea and dehydration, and also to classify for persistent diarrhea and dysentery if present.
  • Checking for feeding problem or low weight
  • Assess immunization
  • Any other problem.

Note: In assessment, if you find a young infant to have a condition requiring urgent referral, continue assessment but skip breastfeeding assessment because it takes some time.

To check young infant for possible bacterial infection

This assessment step is done for a very sick young infant where we look for signs of bacterial infection especially serious infection. It is important to assess the signs in the following order and to keep the infant calm or even asleep.

While assessing the first four signs i.e.

  • counting the respiratory rate
  • looking for chest in-drawing
  • nasal flaring
  • grunting (grunting is soft short noisy sound an infant presents with when breathing out and it occurs when there is troubled breathing).
  • An infant is said to have fast breathing if the rate is 60 or more cycles per minute.
  • Mild chest in-drawing in infants is normal but when it is severe it is a sign of difficulty breathing.
  • Nasal flaring is the widening of the nostrils when the infant is breathing in.
  • To assess the next few signs you need to pick up the infant, undress it, look at the skin allover and take his temperature. By this time the infant will probably b e awake and you can determine whether he is lethargic or unconscious and observe his movements.

Classify for bacterial infection as follows:

Look, listen and feel;

Signs

Classify as

Treatment

Any one of the following signs

  • Not feeding well or
  • Convulsions or
  • Fast breathing (60 bpm or more) or
  • Severe chest in-drawing or
  • Granting or
  • Movement only when stimulated or nor movement even when stimulated or
  • Fever (37.5◦c or above) or
  • Low body temperature (less than 35.5◦c)

VERY SEVERE DISEASE

  • Give first dose of i.v. antibiotics
  • Treat to prevent low blood sugar
  • Advise bthe mother how to keep the infant warm on the way to the hospital
  • Refer urgently to hospital

Signs

Classify

Treatment

  • Red umbilicus or pus draining from the umbilicus
  • Skin pustules

LOCAL BACTERIAL INFECTION

  • Give appropriate oral antibiotic e.g. amoxicillin
  • Teach the mother to treat local infection at home e.g. apply GV
  • Home care for young infant
  • Follow up in 2 days

None of the signs of very severe disease or local bacterial infection

SEVERE DISEASE OR LOCAL INFECTION UNLIKELY

  • Advise mother to give home care for the young infent

Check for Jaundice

Ask: Look, Listen, Feel:

  • Look for jaundice (yellow eyes or skin)
  • Look at young infant palms and soles. Are they yellow?

Classify jaundice

  • Any jaundice if age less than 24 hours or
  • Yellow palms and soles at any age

SEVERE JAUNDICE

  • Treat to prevent low blood sugar
  • Refer urgently to hospital
  • Advise mother how to keep the infant warm on the way to the hospital
  • Jaundice appearing after 24 hours of age and
  • Palms and soles not yellow

JAUNDICE

  • Advise the mother to give home care for the young infant
  • Advise the mother to return immediately if palm and soles appear yellow
  • Follow up in 1 day

No jaundice

NOJAUNDICE

Advise the mother to give home care for the young infant

To assess diarrhea in young infant

If the mother says the young infant has diarrhea, assess and classify for diarrhea.

NB: the normally frequent or loose stools of breastfed baby are not diarrhea but the mother can recognize diarrhea if the consistency and frequency of the stools is different from the normal.

Assessment of diarrhea in a young infant is similar to assessment in a sick child but fewer signs; i.e. thirst is not assessed.

In assessment,

If there is diarrhea;

  • Ask for how long?
  • Is there blood in stool?
  • Look and feel

Signs

Classify

Treatment

Two of the following:

  • Lethargic or unconscious
  • Sunken eyes
  • Skin pinch goes back very slowly

Severe Dehydration

  • If the infant does not have very severe disease
  • Give fluid for severe dehydration (plan C)
  • If the infant also has VERY SEVERE DISEASE:
  • Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
  • Advise mother to continue breastfeeding

Two of the following signs

  • Restless
  • Irritable
  • Sunken eyes
  • Skin pinch goes back slowly

Some dehydration

  • Give fluid and breast milk for some dehydration (plan B)
  • If the infant also has VERY SEVERE DISEASE:
  • Refer URGENTLY to hospital with mother giving sips of ORS on the way
  • Advise mother to continue breast feeding
  • Advise mother when to return immediately
  • Follow up in 2 days
  • Not enough signs to classify as some dehydration or some dehydration

No dehydration

  • Give fluids and breast milk to treat for diarrhea at home (plan A)
  • Advise mother when to return immediately
  • Follow up in two days if not improving

Checking the Young Infant for HIV Infection

Ask:

Has the mother or infant had an HIV test?

What was the resut?

Signs

Classify as

Treatment

Child has positive virological test

CONFIRM HIV INFECTION

  • Give cotrimoxazole prophylaxis from age 4-6 weeks
  • Assess the child’s feeding and counsel as necessary
  • Refer for staging and assessment for ART
  • Advise the mother on home care
  • Follow-up in 14 days

One or both of the following conditions:

  • Mother HIV positive
  • Child has positive HIV antibody test (seropositive)

POSSIBLE HIV INFECTION/HIV EXPOSED

  • Give cotrimoxazole prophylaxis from age 4-6 weeks
  • Assess the child’s feeding and give appropriate feeding advice
  • Refer/ do virological test to confirm infant’s HIV status at least 6 weeks
  • Consider presumptive severe HIV disease

Negative HIV test for mother or child

HIV INFECTION UNLIKELY

  • Treat, counsel and follow-up existing infections
  • Advise the mother about feeding and about her own health

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