IMNCI

IMNCI includes following diseases

• ARI

• Diarrhea

• Measles

• Malaria

• Malnutrition

Distinct features of IMNCI approach

• Syndromic approach

• Holistic approach

• Triage

• Standardized case management

• Primary healthcare model

• Community participation

Age categories in IMNCI-

• Up to 2 months

• 2 months to 5 years

Pink Hospital referral or admission

Yellow Initiation of Treatment

Green Home Treatment

Assessment Of A Young Infant

Assessment (Assess for BCD IF Hypothermic)

• Serious Bacterial infection or local infection

• Jaundice (Color of skin)

• Diarrhea

• Immunization status

• Feeding problem or malnutrition and breast feeding

• Low body temperature (Hypothermic)

Referral For Severe Classifications

• Very severe disease

• Severe jaundice

• Severe dehydration

• Severe persistent diarrhoea

• Severe dysentery

• Not able to feed - possible serious bacterial infection

• Severe malnutrition

Any one of the following signs

Not feeding well

Convulsions

Fast breathing (60 breaths

per minute or more)

Severe chest indrawing

Fever (37.5 °C or above)

Low body temperature (less

than 35.5 °C)

Movement only when

stimulated or no movement at

all.

Pink:

VERY SEVERE

DISEASE

Give first dose of

intramuscular

antibiotics

Treat to prevent low

blood sugar

Refer URGENTLY to

hospital

Advise mother how to

keep the infant warm

on the way to the

hospital

Umbilicus red or

draining pus Skin

pustules

Yellow:

LOCAL BACTERIAL

INFECTION

Give an

appropriate oral

antibiotic

Teach the mother

to treat local

infections at home

Advise mother to

give home care for

the young infant

Follow up in 2

days

Any jaundice if

age less than 24

hours or

Yellow palms

and soles at any

age

Pink:

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

Yellow:

JAUNDICE

Advise the mother to give home

care for the young infant

Advise mother to return immediately

if palms and soles appear yellow.

Body temperature

37.5 °C or above Pink: Very severe disease

37.4 - 36.5 °C Green: Normal

35.5 - 36.4°C Yellow: Low body temperature

< 35.5 °C Pink: Very severe disease

Assessment Of Child Aged 2 M - 5 Years

• Check for general danger signs.

• Ask the mother about the four main symptoms: (CDEF)

• Cough or difficult breathing

• Diarrhea

• Ear problem

• Fever

• Check for signs of malnutrition and anemia

• Check the child’s immunization status

General Danger Signs

• Repeated Vomiting

• Inability to drink or breast-feed

• Convulsions

• Lethargy or Unconsciousness

If a child has any one or more of these signs, he is classified as having very severe disease

Cough or Difficult Breathing

Assess for

(a) Respiratory rate: A child’s age cut-off rate for fast breathing that suggests pneumonia is:

• 2 months up to 12 months: 50 breaths per minute or more

• >12 months up to 5 years: 40 breaths per minute or more

(b) Lower chest wall indrawing

(c) Stridor

Severe Pneumonia

The child is classified as severe pneumonia if • Any general danger signs (VICU) • Stridor in an otherwise calm child Should be referred to a hospital after administering the first dose of injectable antibiotic (IM Chloramphenicol 40mg/kg/dose) or if not possible, give oral amoxicillin 15mg/kg/dose.

Pneumonia

• Fast breathing

• Chest wall indrawing

Management :

• Give oral antibiotics, Amoxicillin for 5 days

• If wheezing, give an inhaled bronchodilator for 5 days

• If coughing for more than 14 days or recurrent wheeze, refer for possible TB or asthma assessment

Cough or Cold

If there are no signs of pneumonia, the classification is cough or cold. Can be managed symptomatically at home and does not warrant antibiotics.

Management:

• If wheezing, give an inhaled bronchodilator for 5 days

• Soothe the throat and relieve the cough with a safe remedy

• If coughing for more than 14 days or recurrent wheezing, refer for possible TB or asthma assessment

Diarrhea

• 0-2 months: Recent change in consistency or pattern of stool as noticed by mother or caregivers

• 2-59 months: Passage of three or more loose stools within 24 hours

Two of the following

signs:

• Lethargic or

unconscious

• Sunken eyes

• Not able to drink

or drinking poorly

• Skin pinch goes

back very slowly.

Pink:

SEVERE

DEHYDRATION

Give fluid for severe

dehydration (Plan C).

If child also has another

severe classification:

Refer URGENTLY to

hospital

Two of the

following signs:

• Restless,

irritable

• Sunken eyes

• Drinks eagerly,

thirsty

• Skin pinch

goes back

slowly.

Yellow:

SOME

DEHYDRATI

ON

Give fluid, zinc supplements,

and food for some dehydration

(Plan B)

If child also has a severe

classification:

Refer URGENTLY to hospital

Not enough signs

to classify as

some or severe

dehydration.

Green:

NO

DEHYDRATI

ON

Give fluid, zinc supplements,

and food to treat diarrhoea at

home (Plan A)

Advise mother when to return

immediately.

Follow-up in 5 days if not

improving

Plan A: Treat Diarrhea at Home (Green)

Give extra fluids

• Up to 2 years: 50 to 100 ml after each loose stool

• 2 years or more: 100 to 200 ml after each loose stool

Give Zinc Supplements

• 2-6 months – 10 mg/day for 14 days

• 6-59 months – 20 mg/day for 14 days

• Exclusively breastfed infants less than 2 months of age, should be given ORS only if already dehydrated, while those between 2-6 months should be given ORS even if no dehydration.

Plan B: Treat Some Dehydration with ORS (Yellow)

• Give recommended amount of ORS over a 4-hour period

• Amount of ORS required (in ml) - multiplying the child’s weight (in kg) times 75

• After 4 hours, Reassess the child and classify for dehydration

Plan C: Treatment of Severe Dehydration (Pink)

Give 100 ml/kg Ringers lactate solution or Normal saline as follows

Age First give 30 ml/kg in* Then give 70 ml/kg in

Infants 1 hour 5 hours

1-5 years 30 minutes 2 ½ hours

Dysentery

Blood in the stool

but no dehydration

Dysentery Give ciprofloxacin for 3

days

Blood in the stool in

a young infant

Severe

Dysentery

Give first dose of

intramuscular ampicillin

and gentamicin

Persistent Diarrhea

Diarrhea lasting for 14 days or more

Dehydration

present

Severe

persistent

diarrhea

Treat dehydration before referral

Refer to hospital

No

Dehydration

Persistent

diarrhea

Give multivitamins and minerals

(including zinc) for 14 days

Give Vitamin A treatment

Composition - ORS

Sodium chloride 2.6 gm

Trisodium citrate dehydrate 2.9 gm

Potassium chloride 1.5 gm

Glucose 13.5 gm

Electrolyte Composition - ORS

Sodium 75 mmol

Citrate 10 mmol

Potassium 20 mmol

Glucose 75 mmol

Chloride 65 mmol

Total osmolality 245 mmol

Fever

Any general

danger sign or

Stiff neck

Pink:

Very

severe

Febrile

Disease

• Give first dose of Artesunate or

Quinine for severe malaria

• Give first dose of IV or IM

chloramphenicol

• Treat the child to prevent low blood

sugar.

• Give paracetamol

• Refer URGENTLY to hospital.

Fever

and

Malaria test

positive

Yellow:

Malaria

• Give recommended oral antimalarial

• Give paracetamol

• Give appropriate antibiotic

Fever

and

Malaria test

Negative

Green:

Fever,

No

malaria

• Give Paracetamol

• Give appropriate antibiotic

Measles

A child with fever is assessed for signs of measles such as generalized rash with cough, runny nose and red eyes

Any general

danger sign

or

Clouding of

cornea or

Deep or

extensive

mouth ulcers.

Pink:

Severe

Complicated

Measles

• Give Vitamin A Treatment

• Give first dose of injectable

chloramphenicol

• 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.

Yellow:

Measles with

eye or mouth

complications

• Give Vitamin A treatment

• If pus draining from the eye,

treat with tetracycline eye

ointment.

• If mouth ulcers, treat with

gentian violet

Measles now or

within the last

3 months.

Green:

Measles

Give Vitamin A treatment

Ear problem

Tender swelling

behind the ear

Pink:

Mastoiditis

• Give first dose of

injectable

chloramphenicol

• Give first dose of

paracetamol

• Refer URGENTLY to

hospital

Pus from the ear

and discharge for

less than 14 days,

or

Ear pain

Yellow:

Acute ear

infection

• Give Amoxicillin for 5

days.

• Give paracetamol.

• Dry the ear by wicking.

Pus from the ear

and discharge for

14 days or more.

Yellow:

Chronic ear

infection

• Dry the ear by wicking

• Treat with topical

quinolone eardrops for 14

days

Acute malnutrition

Edema of feet

OR

WFH/L less than -3 z- scores

OR

MUAC less than 115 mm

AND

Any one of the following:

Medical complication present

or

Not able to finish RUTF or

Breastfeeding problem

Pink:

Complicated

Severe Acute

Malnutrition

Give first dose

appropriate

antibiotic

Treat the child to

prevent low blood

sugar

Keep the child

warm

Refer URGENTLY

to hospital

WFH/L less than -3 z-

scores

OR

MUAC less than 115 mm

AND

Able to finish RUTF

Yellow:

Uncomplicated

Severe Acute

Malnutrition

• Give antibiotics for

5 days

• Give RUTF

• Counsel the

mother on how to

feed.

WFH/L between -3

and - 2 z-scores

OR

MUAC 115 up to 125

mm

Yellow:

Moderate Acute

Malnutrition

Counsel the mother on

the feeding

recommendations

Assess for possible TB

infection.

WFH/L - 2 z-scores or

more

OR

MUAC 125 mm or

more

Green:

No Acute

Malnutrition

Assess the child's feeding

and counsel the mother

on feeding

Anemia

• Palmar pallor is looked for in every sick child presenting to primary health care.

Severe palmar

pallor

Severe Anemia Refer urgently

Some palmar pallor Anemia Give Iron

Give Albendazole

No Palmar Pallor No Anemia Give IFA Prophylactically

IMNCI was taken to prevent morbidity and mortality from all except- (AIPGME 2008)

a) Malaria

b) Malnutrition

c) Otitis media

d) Neonatal tetanus

IMNCI differs from IMCI in all of the following, except: (AIPGME 2010)

a) Malaria and anemia are included

b) 0-7 days neonates are included

c) Emphasis on management of sick neonates over sick older children

d) Treatment is aimed at more than one disease at a time

IMNCI includes all except- (AIPGME 2009)

a) Malaria

b) Respiratory infections

c) Diarrhea

d) Tuberculosis

Acute Respiratory Infections (ARI) are important causes of under-five mortality in India. In remote areas, children develop frequent episodes of ARI. What measures will you take for prevention and control of ARI amongst under-five children in that area? (UPSC CMS 2015)

a) Case management and Health education to mothers

b) Vaccination

c) Controlling malnutrition, Promoting breast feeding and vitamin A supplementation

d) All of these

The total osmolarity of new oral rehydration solution formulation is: (UPSC CMS 2013)

a) 210 mmol/litre

b) 245 mmol/litre

c) 255 mmol/litre

d) 300 mmol/litre

What is the potassium concentration in WHO ORS solution? (JIPMER-2000)

a) 10meq

b) 20meq

c) 30meq

d) 40meq

A 15-month-old child presents with fever and cough since the last two days, the respiratory rate is 55/min and there is no indrawing of the chest. According to the National Programme for Acute Respiratory Infections, the line of management should be (UPSC CMS 2011)

a) Immediate referral of the child to hospital for urgent admission

b) Referral of the child to hospital for admission, after administration of first dose of antibiotic

c) Administration of antibiotic at home, along with treatment for fever, advising the mother to return for reassessment after two days

d) Administration of treatment for fever at home, advising the mother to return after two days for assessment of the need for an antibiotic

A 10-months old child is brought to a PHC with history of cough and cold. On examination, he has respiratory rate of 48 breaths per minute and there is absence of chest indrawing. His weight is 5 kg. He is probably suffering from (AIIMS 2014)

a) No pneumonia

b) Pneumonia

c) Severe Pneumonia

d) Very severe pneumonia

A neonate was brought with fever and has respiratory rate of 72/min. The classification of such a child in IMNCI will be as-

a) Pneumonia

b) Severe pneumonia

c) Severe bacterial infection

d) Very severe disease

A 3-year-old child was brought at a PHC with high-grade fever, inability to drink and repeated vomiting. He has no cough or diarrhea. The incorrect statement regarding the management of this child is-

a) Classify as Very Severe Disease

b) Pre-referral treatment with IM Quinine and Chloramphenicol

c) Give Paracetamol parenterally if fever is more than 38.5 degrees Celsius

d) Classify as Very serious febrile disease

As per IMNCI guidelines, a child has been diagnosed with some dehydration and started on Plan B. His age is one year and weighs 10 kg. He should be given ________ ml of ORS in four hours.

a) 400

b) 600

c) 800

d) 1000

In a 6 month old child breathing rate ___________ or more suggests pneumonia:

• 40 per minute

• 50 per minute

• 60 per minute

• 70 per minute

Signs for classifying a child under IMNCI as having severe dehydration are all except:

a) Dry tongue

b) Sunken eyes

c) Not able to drink

d) Lethargic or unconscious

A child aged 24 months was brought to the Primary Health Centre with complaints of cough and fever for the past 2 days. On examination, the respiratory rate was 48 per minute, chest indrawing and stridor were present. The most appropriate line of management for this patient is?

a) Classify as pneumonia and refer urgently to secondary level hospital.

b) Classify as pneumonia, start antibiotics and advise to report after 2 days.

c) Classify as severe pneumonia, start antibiotics and refer urgently.

d) Classify as severe pneumonia and refer urgently.

La fin