- 1.Integrated Management of Neonatal and Childhood Illness
(IMNCI)1
2. Plan of presentation Background for IMCI Rationale for IMNCI
IMNCI 2- 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.
Introduction 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 3 bulletin) and now as above. 4.
Background of IMCI Every year more than 10 million children die
indeveloping countries before they reach their fifth birthday. 7 in
10 of these deaths are due to five preventableand treatable
conditions. Pneumonia,diarrhoea,malaria,measlesandmalnutrition and
often to a combination of these 4conditions. 5. Causes of Child
deaths5 6. Background of IMCI (Contd) The 5 main killers of
children: ARI, diarrhoea, measles, malaria and malnutrition In
India, common illnesses in children under 3years 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 * National Family Health Survey-
India, 1998-99 providers, and and treated by these health care 6**
Global Burden of disease, WHO, Geneva, 1996 that their parents are
poorly advised.199055%Perinatal conditionsOther communicable
diseasesNon-communicable diseasesInjuries19%12% 7. Infant mortality
trend in India7 8. Neonatal mortality in India8 9. IMR and MDG9 10.
Rationale for an integrated evidence based syndromic approach to
case management Many well-known prevention and treatment strategies
have 10already 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 11. Key features of IMCI IMCI is an integrated
approach to child health thatfocuses on the well-being of the whole
child. IMCI aims to reduce death, illness and disability andto
promote improved growth and development amongchildren under 5 years
of age. IMCI strategy promotes the accurate identification
ofchildhood illnesses in out patient settings. Ensuresillnesses.
11appropriate combined treatment of all 12. Key features of IMCI
(Contd. . .) Strengthens the counseling of caretakers. Speeds up
the referral of severely ill children. Promotesappropriate care
seeking behaviors, improved nutrition & preventive care &
correct implementation of prescribed care. Provision of home based
newborn care to 1.promote exclusive breastfeeding2.prevent
hypothermia12 3.improve illness recognition & timely care
seeking 13. IMNCI- India Home visits for young infants: Schedule
All newborns: 3 visits (within 24 hours of birth, day 3-4 andday
7-10) Newborns with low birth weight: 3 more visits on day 14,
21and 28. 13 14. IMCI Process:Source: IMCI; Students Handbook, WHO
15. IMNCI- India Incorporation of neonatal care as it now
constitutes twothirds 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 infantand sick child is almost equal. 15
Skill based. 16. Difference between IMCI and IMNCI Features:WHO
UNICEF IMCIIMNCICoverage of 0 to 6 days (early newborn
period)NoYesBasic Health Care ModuleNOYesHome visit by the provider
for newborn and Young InfantNoYesTrainingTraining Home based
CareNoTraining days for newborn and 2 out of 11 days young infants
Sequence of trainingYes4 out of 11 daysChild (2 months to 5 years
of Newborn and young infants (0 age) then Young infant ( 7 days to
2 months).Then Child (from to 2 months of age) 2 months to 5 years
of age.) 17. 17 18. Up to 50% of neonatal deaths are in the first
24 hours75% of neonatal deaths are in the first week 3 million
deaths18Timewhen most babies die is when coverage of care is lowest
19. Guidelines for IMNCI Evidence-based, syndromic approach to
case19management 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 decisionmaking. 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 childs
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 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. ii.
Improvements in the overall health system required for effective
management of neonatal and childhood illness. iii. Improvements in
family and community health care practices. i.21 22. 22 23.
Principles of integrated care All sick young infants up to 2 months
of age must beassessed 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
beexamined 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. 23 24. Principles of
integrated care (Contd. .) All sick young infants and children 2
months upto 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 24 25.
Principles of integrated care (Contd. .) They call for specific
actions based on whether the child - 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) Use of limited number of essential drugs and encourage
25active participation of caretakers in the treatment of 26. IMNCI
is a Key Strategy for Improving Child Health By
integrationManagement of sick childrenNutritionIntegrated
Management of Childhood IllnessImmunizationOther disease prevention
Promotion of growth and development 27. Elements of case management
process 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 herown
health aswell as to follow further instructions onfurther child
care. 27 Follow up care - Reassess the child for new problems. 28.
The case management process28 29. IMCI case management at first
level health facility, referral level, and home :29 30. Integrated
Case Management Process for the sick young infant up to 2 months of
age30 31. Assess , classify and treat the sick young infant up to 2
months31 32. Look listen feel32 33. Assess and classify young
infant for diarrhoea33 34. Feeding problem and malnutrition chart34
35. Treatment of sick young infants35 36. 36 37. 37 38. Counseling
a mother or caretaker Ask and Listen Praise Advice CheckEssential
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 38 Counsel the mother
about her own health 39. Mothers card39 40. Prescription slip40 41.
Integrated Case Management Process of children age 2 months up to 5
years41 42. 42 43. 43 44. Cough or difficult breathing44 45.
Diarrhoea45 46. Malaria & Measles46 47. Ear problem chart47 48.
Malnutrition chart48 49. 49 50. Anaemia chart50 51. Treatment
procedures for sick children51 52. 52 53. Facility based -IMNCI
Acute shortage of Pediatricians in the country; asagainst 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.53* Bulletin on Rural Health Statistics 54. F-IMNCI F-
IMNCI is an integration of the existing IMNCI packageand the
Facility Based Care package in to one. From November 2009 IMNCI has
been re -baptized as FIMNCI, (F -Facility) with added component of:
1. Asphyxia Management and 2. 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 54 and children, the
F-IMNCI training will therefore help in skill building of the
medical officers and staff nurses posted in 55. Components of
F-IMNCI Skill based training Improvements to the health system
:Logistics/Manpower/ Referral mechanisms Improvement of Family and
Community Practices 55 56. Institutional arrangements State level
District level Trainee: Trainers: Training of trainers: Number to
be trained: Training institutions: Funding :56 57. C - IMNCI:
Community and Household IMNCI: Community IMNCI is basically
Component 3 of theIMCI 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.
57 58. C - IMNCI: cont. 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 childs 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. 58 Provide appropriate
care for HIV/AIDS affected people, especially orphans, and Take
action to prevent further HIV infections. 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 providers advice on treatment,
follow-up and 59 referral. Ensure that every pregnant woman has
adequate antenatal care, 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 As of December 2009,
about 297 districts areimplementing 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.62 63. Strengths of IMNCI Evidence based
management decisions. Feasible to incorporate into both
pre-servicetraining & in-service training. Hands-on clinical
training for 50% of training time. Focus on communication &
counselling skills. Locally adapted recommendations for infant
andyoung child feeding. Cost effective. Lowers the burden to
hospitals. Model to improve health care. 63 64. Challenges of IMNCI
Issues regard to safe home delivery. A referral system with
linkages between the 64different 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 65. References 1. Integrated management of
neonatal and childhood illness. Modules 1 to 9. 2.3. 4. 5. 6.
7.65Ministry of health & Family welfare, Government of India,
New Delhi. 2009. Students 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. 21st 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. IMNCI In an effort to meet Millennium Goals67
