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WHAT IS IMCI?
• A strategy for reducing mortality and morbidity associated with major causes of childhood illness
• A joint WHO/UNICEF initiative since 1992
• Currently focused on first level health facilities
• Comes as a generic guidelines for management which have been adapted to each country
Pneumonia, diarrhea, dengue hemorrhagic fever, malaria, measles and malnutrition cause more than 70% of the deaths
in children under 5 years of age. All these are preventable diseases in which when managed and treated early could have
prevented these deaths. There are feasible and effective ways that health worker in health centers can care for children with
these illnesses and prevent most of these deaths. WHO and UNICEF used updated technical findings to describe
management of these illnesses in a set of integrated guidelines for each illness. They then developed this protocol to teach
the integrated case management process to health worker who see sick children and know which problems are most
important to treat. Therefore, effective case management needs to consider all of a child’s symptoms.
• For those children who can be treated at home, caregivers are taught how to provide treatment and when
to seek care for their children. The guidelines also identify actions to prevent illness through the immunization of
sick children, supplementation of micronutrients, promotion of breastfeeding, and counseling of mothers to solve
feeding problems. It is also an important factor to teach families when to seek care for a sick child as part of the
case management process. This approach, which combines steps to manage and prevent several different
conditions, is comprehensive and systematic.
DISTRIBUTION OF 11.6 MILLION DEATHS AMONG CHILDREN LESS THAN 5 YRS OLD IN ALL DEVELOPING
COUNTRIES, 1995
• MALNUTRITION 54%
• Others 32%
• ACUTE RESPIRATORY INFECTIONS (ARI) 19 %
• DIARRHEA 19%
• Perinatal 18%
• MEASLES 7%
• MALARIA 5%
OBJECTIVES OF IMCI
• To reduce significantly global morbidity and mortality associated with the major causes of illnesses in
children
• To contribute to healthy growth and development of children
is used to assess and classify two age groups : age 1 week up to 2 months age 2 months up to 5 years And how to use
the process shown on the chart will help us to identify signs of serious disease such pneumonia, diarrhea, malaria, measles,
DHF, meningitis, malnutrition and anemia.
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THE CASE MANAGEMENT PROCESS :
The classification tables on the assess and classify have 3 ROWS . COLOR of the row helps to IDENTIFY RAPIDLY
whether the child has a SERIOUS DISEASE requiring URGENT ATTENTION.
PINK – means the child has a severe classification and needs urgent attention and referral or admission for inpatient
care.
YELLOW – means the child needs a specific medical treatment such as an appropriate antibiotic, an oral anti-malarial
or other treatment; also teaches the mother how to give oral drugs or to treat local infections at home. The health worker
teaches the mother how to care for her child at home and when she should return.
GREEN – not given a specific medical treatment such as antibiotics or other treatments. The health worker teaches the
mother how to care for her child at home.
Always start at the top of the classification table. If the child has signs from more than 1 row always select the more
serious classification.
WHY NOT USE THE PROCESS FOR CHILDREN AGE 5 YEARS OR MORE?
• The case management process is designed for children < 5yrs of age, although. Much of the advise on
treatment of pneumonia, diarrhea, malaria, measles and malnutrition, is also applicable to older children, the
ASSESSMENT AND CLASSIFICATION of older children would differ. For example, the cut off rate for
determining fast breathing would be different because normal breathing rates are slower in older children. Chest
indrawing is not a reliable sign of severe pneumonia as children get older and the bones of the chest become
more firm.
• In addition, certain treatment recommendations or advice to mothers on feeding would differ for >5yrs old.
The drug dosing tables only apply to children up to 5yrs old. The feeding advice for older children may differ and
they may have different feeding problems.
• Because of differences in the clinical signs of older and younger children who have these illnesses, the
assessment and classification process using these clinical signs is not recommended for older children.
WHY NOT USE THIS PROCESS FOR YOUNG INFANTS AGE < 1 WEEK OLD?
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• The process on young infant chart is designed for infants age 1 week up to 2 months. It greatly differs
from older infants and young children. In the first week of life, newborn infants are often sick from conditions
related to labor and delivery. Their conditions require special treatment.
• Curative component adapted to address the most common life-threatening conditions in each country
• Rehydration (diarrhea, DHF)
• Antibiotics (pneumonia, “severe disease”)
• Antimalarial treatment
• Vitamin A (measles, severe malnutrition)
Learning Objectives
• Outpatient
o 1 - assessment
o 2 - classification and identification of treatment
o 3 - referral, treatment or counseling of the child’s
o caretaker (depending on the classification identified)
o 4 - follow-up care
• Referral Health Facility
o 1 - emergency triage assessment and treatment
o 2 - diagnosis, treatment and monitoring of
• patient’s progress
For all sick children age 1 week up to 5 years who are brought to a first-level health facility
• ASSESS the child: Check for danger signs (or possible bacterial infection). Ask about main symptoms. If
a main symptom is reported, assess further. Check nutrition and immunization status. Check for other problems .
• CLASSIFY the child’s illnesses : Use a colour-coded triage system to classify the child’s main symptoms
and his or her nutrition or feeding status.
• IF URGENT REFERRAL is needed and possible
• IF NO URGENT REFERRAL isneeded or possible
• IDENTIFY URGENT PRE-REFERRAL TREATMENT(S) needed for the child’s classifications.
• IDENTIFY TREATMENT needed for the child’s classifications: Identify specific medical treatments and/or
advice.
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• TREAT THE CHILD: Give urgent pre-referral treatment (s) needed.
• TREAT THE CHILD: Give the first dose of oral drugs in the clinic and/or advise the child’s caretaker.
Teach the caretaker how to give oral drugs and how to treat local infections at home. If needed, give
immunizations.
• REFER THE CHILD: Explain to the child’s caretaker the need for referral. Calm the caretaker’s fears and
help resolve any problems. Write a referral note. Give instructions and supplies needed to care for the child on the
way to the hospital.
• COUNSEL THE MOTHER : Assess the child’s feeding, including breastfeeding practices, and solve
feeding problems, if present. Advise about feeding and fluids during illness and about when to return to a health
facility. Counsel the mother about her own health.
• FOLLOW-UP care: Give follow-up care when the child returns to the clinic and,if necessary, reassess the
child for new problems.
SELECTING THE APPROPRIATE CASE MANAGEMENT CHARTS FOR ALL SICK CHILDREN age 1 week up to 5 years
who are brought to the clinic
ASK THE CHILD’S AGE IF the child is from 1 week up to 2 months IF the child is from 2 months up
USE THE CHART: ASSESS AND CLASSIFY THE SICK CHILD TREAT THE CHILD COUNSEL œ USE THE CHART:
THE MOTHER
Ask the mother or caretaker about the child’s problem. If this is an INITIAL VISIT for the problem, follow the steps below. (If
this is a follow-up visit for the problem, give follow-up care according to PART VII) Check for general danger signs. Ask the
mother or caretaker about the four When assess the child further for signs œ a main symptom is present: main symptoms:
œ cough or difficult breathing, the main symptom, and œ related to fever, and チ œ œ classify the illness according
to the signs œ diarrhoea, ear problem which are present or absent. Check for signs of malnutrition and anaemia and
classify the child’s nutritional status Check the child’s immunization status and decide if the child needs any immunizations
today. Assess any other problems. Then : Identify Treatment (PART IV), Treat the Child (PART V), and Counsel the Mother
(PART VI)
SUMMARY OF ASSESS AND CLASSIFY Ask the mother or caretaker fever,◊ diarrhoea ◊ cough or difficult breathing ◊about
the 4 main symptoms: Assess the child further for◊ ear problem When a main symptom is present: ◊and Classify the illness
according to the◊signs related to the main symptom, and signs which are present or absent
FOR ALL SICK CHILDREN AGE 2 MONTHS UP TO 5 YEARS WHO ARE BROUGHT TO THE CLINIC GREET the mother
appropriately and ask about her child. LOOK to see if the child’s weight and temperature have been recorded ASK the mother
what the child’s problems are DETERMINE if this is an initial visit or a follow-up visit for this problem IF this is an INITIAL
VISIT for the problem ASSESS and CLASSIFY the child following the guidelines in this part of the handbook (PART II) GIVE
FOLLOW-UP CARE according to the guidelines in PART VII of this handbook When a child is brought to the clinic IF this is a
FOLLOW-UP VISIT for the problem Use Good Communication skills: (see also Chapter 25) — Listen carefully to what the
mother tells you . — Use words the mother understands — Give the mother time to answer the questions . ---Ask additional
questions when the mother is not sure about her answer . Record Important Information
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• Record important information
GENERAL DANGER SIGNS For ALL sick children ask the mother about the child’s problem, then
CHECK FOR GENERAL DANGER SIGNS A child with any general danger sign needs URGENT attention;
the child had convulsions? Make sure that a child with any danger sign is referred after receiving urgent pre-referral
treatment. Then ASK about main symptoms: cough and difficult breathing, diarrhoea, fever, ear problems.
CHECK for malnutrition and anaemia, immunization status and for other problems.
• ASK:
• Is the child able to drink or breastfeed?
• Does the child vomit everything?
• Has the child had convulsions?
• LOOK:
• See if the child is lethargic or unconscious
Fast breathing is
CHILD MUST BE CALM CLASSIFY the child’s illness using the color-coded classification table for cough or difficult
breathing.
Then ASK about the main symptoms : fever, ear problem, and CHECK for malnutrition and anemia, immunization status
and for other problems
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For ALL sick children ask the mother about the child’s problem, check for general danger signs, Ask about cough or
difficult breathing and then
• IF YES, ASK:
• For how long?
• LOOK, LISTEN, FEEL:
• Count the breaths in one minute.
• 2-12 mos = fast breathing >/= 50/min
• 12 mos-5yrs = fast breathing >/= 40/min
• Look for chest indrawing
• Look and listen for stridor
• Classify COUGH or DIFFICULT BREATHING
CLASSIFICATION TABLE FOR COUGH OR DIFFICULT BREATHING SIGNS CLASSIFY AS IDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
PNEUMONIA
• Fast breathing
• Give first dose of an appropriate antibiotic.
• Refer URGENTLY to hospital.
Diarrhea
• For ALL sick children ask the mother about the child’s problem,
• check for general danger signs,
• ask about cough or difficult breathing and dehydration
• Does the child have diarrhea?
• IF YES , ASK:
• For how long?
• Is there blood in the stool?
• LOOK, LISTEN, FEEL: Look at the child’s general condition,
• is the child: Lethargic or unconscious?
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• Restless or irritable? Look for sunken eyes Offer the child fluid.
• Is the child: Not able to drink or drinking poorly?
• Drinking eagerly, thirsty ?
• Pinch the skin of the abdomen.
• Does it go back: Very slowly (> than 2 secs)?
• Slowly?
• NO DEHYDRATION
SOME DEHYDRATION
— 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.
SEVERE DEHYDRATION
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Lethargic or unconscious
Sunken eyes
Not able to drink or drinking poorly
Skin pinch goes back very slowly
PERSISTENT DIARRHEA
No dehydration
Treat dehydration before referral unless the child has another severe classification.
Refer to hospital.
Dehydration present
Treat for 5 days with an oral antibiotic recommended for Shigella in your area.
Follow-up in 2 days.
DYSENTERY
FEVER
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-Runny nose -Clouding of cornea
-Red eye
CLASSIFY the child’s illness using the œ colour-coded classification tables for fever.
Then ASK about the next main symptom: ear problem,
and CHECK for malnutrition and anaemia, immunization status and for other problems.
LOOK FOR SIGNS OF DENGUE/DHF -bleeding tendencies -flushing -(+) tourniquet test -rash
CLASSIFICATION TABLE FOR NO MALARIA RISK AND NO TRAVEL TO A MALARIA RISK AREA
Give one 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.
CLASSIFICATION TABLE FOR MEASLES (IF MEASLES NOW OR WITHIN THE LAST 3 MONTHS)
—pneumonia, stridor, diarrhoea, ear infection, and malnutrition—are classified in other tables.
Give vitamin A.
If pus draining from the eye, treat eye infection with tetracycline eye ointment.
If mouth ulcers, treat with gentian violet.
Follow-up in 2 days.
MEASLES
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Give first dose of an appropriate antibiotic.
If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment.
Refer URGENTLY to hospital.
For ALL sick children ask the mother about the ask about cough or difficult breathing, diarrhoea, fever and then ASK: DOES
THE CHILD HAVE AN EAR PROBLEM?
IF YES ASK:
Is there ear pain?
Is ther 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 the child’s illness using the colour-coded-classification table for ear problem. Then CHECK for
malnutrition and anaemia, immunization status and for other problems.
Pus is seen draining from the ear and discharge is reported for 14 days or more.
Give an oral antibiotic for 5 days.
Give paracetamol for pain.
Dry the ear by wicking.
Follow-up in 5 days.
Pus is seen draining from the ear and discharge is reported for less than 14 days, or
Ear pain.
Give first dose of an appropriate antibiotic.
Give first dose of paracetamol for pain.
Refer URGENTLY to hospital.
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CHECK FOR MALNUTRITION AND ANEMIA
LOOK AND FEEL:
Look for visible severe wasting
Look for palmar pallor. Is it:
Severe palmar pallor?
Some palmar pallor?
Look for edema of both feet
Determine weight for age
CLASSIFY NUTRITIONAL STATUS
— Not very low weight for age and no other signs or malnutrition.
— Assess the feeding according to the FOOD box on the COUNSEL THE MOTHER chart.
— If feeding problem, follow-up in 5 days.
— If pallor:
— Give iron.
— Give oral antimalarial if high malaria risk .
— Give mebendazole if child is 2 years or older and
— has not had a dose in the previous 6 months.
— Advise mother when to return immediately.
— If pallor, follow-up in 14 days.
— If very low weight for age, follow-up in 30 days.
Immunization Status
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THEN CHECK THE CHILD’S IMMUNIZATION STATUS For ALL sick children
ask the mother about the child’s about cough or difficult breathing, diarrhoea, fever, ear problem, and then check for
malnutrition and anaemia and
OPV-0 OPV-1 OPV-2 OPV-3 VACCINE BCG DPT-1 DPT-2 DPT-3 Measles
AGE Birth 6 weeks 10 weeks 14 weeks 9 months
IMMUNIZATION SCHEDULE: DECIDE if the child needs an immunization today, or if the mother should be told to come back
with the child at a later date for an immunization.
Note: Remember there are no contraindications to immunization of a sick child if the child is well enough to go home. Then
CHECK for other problems.
Immunization Status
— BCG
— DPT 1 , OPV 1
— Hepatitis B 1
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YOUNG INFANT MUST BE CALM
For ALL sick young infants check for signs of POSSIBLE BACTERIAL INFECTION
ASK:
Has the infant had convulsions?
LOOK, LISTEN, FEEL:
Count the breaths in one minute.
Repeat the count if elevated.
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?
Does the redness extend to the skin?
Measure temperature (or feel for fever or low body temperature)
Look for skin pustules. Are there many or severe pustules?
See if the young infant is lethargic or unconscious.
Look at the young infant’s movements. Are they less than normal?
CLASSIFY the infant’s illness using the COLOUR-CODED-CLASSIFICATION TABLE FOR POSSIBLE
BACTERIAL INFECTION.
Then ASK about diarrhea.
CHECK for feeding problem or low weight, immunization status and for other problems.
These thresholds are based on axillary’s temperature.
The thresholds for rectal temperature readings are approximately 0.5 ° C higher.
Convulsions or
Fast breathing (60 breaths per minute or more) or
Severe chest indrawing or
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Nasal flaring or
Grunting or
Bulging fontanelle or
Pus draining from ear or
Umbilical redness extending to the skin or
Fever (37.5 C* or above or feels hot) or low body temperature (less than 35.5 C* or feels cold) or
Many or severe skin pustules or
Lethargic or unconscious or
Less than normal movement.
For ALL sick young infants check for signs of possible bacterial infection and then
For ALL sick young infants check for signs of possible bacterial infection,
IF AN INFANT:
ASSESS BREASTFEEDING:
NO FEEDING PROBLEM
Not low weight for age and no other signs of inadequate feeding.
Advise the mother to breastfeed as often and for as long as the infant wants, day and night.
-If not well attached or not suckling effectively, teach correct positioning and attachment.
-If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding.
If receiving other foods or drinks, counsel mother about breastfeeding more, reducing other foods or
drinks, and using a cup.
Follow-up care for the sick young infant When to return immediately
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Name:___________ Age:___________ Weight:____________________ kg________________________
Temperature:_______________ C ASK: What are the infant's problems?__________________________________
Initial visit?_________________ Follow-up Visit?______________ ASSESS (Circle all signs present) CLASSIFY
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CLASSIFY
TREAT Return for follow-up on _________________ Give any immunization/s needed today.
Name: ___________________________________________________________________
Age:____________________Weight:_______kg Temperature:________
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CLASSIFY MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5 C or above) Yes ___ No ___
LETHARGIC OR UNCONSCIOUS CHECK FOR GENERAL DANGER SIGNS NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING CONVULSION
if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years old FEEDING PROBLEMS
IMMUNIZATION STATUS
_______ _______ ______ ______ ________ OPV 0 OPV 1 OPV 2 OPV 3 Measles
Yes___ No___
Look for pus draining from the ear.
Feel for tender swelling behind the ear.
DOES THE CHILD HAVE AN EAR PROBLEM?
Is there ear pain?
Is there ear discharge?
If Yes, for how long? ___ Days
Advice mother when to return immediately. Give any immunization/s needed today. Feeding Advice
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Category A – Province with no significant improvement in malaria situation in the last 10 years or situation
worsened in the last 5 yrs; average no. of cases >1000 in the last 10 yrs
Category B – Provinces where situation has improved in the last 5yrs or average no. of cases 100 to <1000
cases/yr
- Abra - Laguna
- Pangasinan - Camarines Norte
- Ilocos norte - Camarines Sur
- Nueva Vizcaya - Sultan Kudarat
- Nueva Ecija - So. Cotabato
- Bulacan - North Cotabato
- Bataan - Lanao del Sur
- Mindoro Or - Lanao del Norte
- Rizal - Maguindanao
- Aurora - Zamboanga del Norte
- Tarlac - Romblon
- Benguet - Antique
- Ilocos Sur - Sorsogon
- La Union - Negros Occ
- Pampanga - Negros Or
- Batangas - Eastern Samar
- Cavite - Western Samar
- Marinduque - Misamis Occ
- Masbate - Surigao del Norte
- Batanes - Albay
Category D – Provinces that are malaria-free although some are still potentially malarious sue to toe presence of
the vector.
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