IMCI STRATEGY

Integrated Management of Childhood Illness

Figure 1: Distribution of 11.6 million deaths among children less than 5 years old in all developing countries,1995
Malaria Measles 5% 7% Malnutrition 54% Diarrhoea 19%

Acute Respiratory Infections ( ARI ) 19%

Other 32%

Perinatal 18%

* Approximately 70% of all childhood deaths are associated with one or more of these 5 conditions

Based on data taken from The Global Burden of Diaease 1996,edited by Murray CJL and Lopez AD, and Epidemiologic evidence for a potentiating effect of malnutrition on child mortality, Pelletler DL, Frongillo EA and Hablcht JP, AMJ Public Health 1993;83:1130-1133

Integrated management of childhood illness (IMCI) Objectives

To reduce significantly global mortality and morbidity associated with the major causes of disease in children To contribute to healthy growth and development of children

Integrated Management of Childhood Illness (IMCI) Components

Improving case management skills of health workers standard guidelines training (pre- and in- service) Follow-up after training

Improving the health system to deliver IMCI essential drug supply and management organization of work in health facilities management and supervision
Improving family and community practices

Integrated Management of Childhood Illness (IMCI)

Birth 1 week 2 months
Pregnancy

5 years

IMCI case management guidelines

For many sick children a single diagnosis may not be apparent or appropriate
Presenting complaint Cough and/or fast breathing Possible cause or associated condition
Pneumonia Severe anemia P. falciparum malaria Celebral malaria Meningitis Severe dehydration Very severe pneumonia Pneumonia Diarrhea Ear infection Pneumonia Meningitis Sepsis

Lethargy or unconsciousness

Measles

Very sick young infant

Integrated management of childhood illness (IMCI) as a key strategy for improving child health
Management of sick children Nutrition Immunization Other disease prevention Promotion of growth and development

Integrated management of Childhood illness (IMCI)

Figure 4: Interventions currently included in the IMCI strategy

Promotion of growth Prevention of disease
Community/home based interventions to improve nutrition -insecticide impregnated bednets

Response to sickness (curative care)

-Early case management -Appropriate care seeking -Compliance with treatment

Home Health -Vaccination services -Complementary feeding and

breastfeeding counseling -Micronutrient supplementation -Case management of: ARI, Diarrhea,measles,malaria, Malnutrition, other serious infection. -Complementary feeding and breastfeeding counseling -Iron treatment -Antihelminthic treatment

IMCI Brings it All Together

Case management

Guidelines and training

for individual diseases Health education activities for individual diseases

Integrated case management guidelines training and follow-up

Health Worker skills

Interventions to improve family and community practices

Family and community

Drug supply and management District management of health services Health system reform

Health system

Many programmes benefit from the IMCI strategy Programme

ARI and CDD EPI Malaria control Maternal health Nutrition

What IMCI offers

Integrated case management Less missed opportunities Improved care of childhood malaria Promotion of bednets Opportunity to discuss mothers health and provide services Locally adapted feeding guidelines Nutrition and breastfeeding counseling Drug policies for childhood diseases Standard treatment guidelines

Essential drugs

Benefits of Integrated Management of Childhood Illness (IMCI) The IMCI strategy:

Addresses major health problems Responds to demand Is likely to have a major impact on health status Promotes prevention as well as cure is cost-effective Promotes cost saving Improves equity

THE INTEGRATED CASE MANAGEMENT PROCESS

OUTPATIENT HEALTH FACILITY
Check for DANGER SIGNS
Convulsions Abnormally sleepy or difficult to awaken Unable to drink/breastfeed Vomits everything

Assess MAIN SYMPTOMS

Cough/difficulty breathing Diarrhea Fever Ear problems

Assess NUTRITION, IMMUNIZATION and VITAMIN A SUPPLEMENTATION STATUS and POTENTIAL FEEDING PROBLEMS

Check for OTHER PROBLEMS

CLASSIFY CONDITIONS and IDENTIFY TREATMENT ACTIONS According to color-coded treatment

Urgent referral OUTPATIENT HEALTH FACILITY Pre-referral treatments Advise parents Refer child

Treatment at outpatient health facility OUTPATIENT HEALTH FACILITY Treat local infection Give oral drugs Advise and teach caretaker follow-up

Home management HOME Caretaker is counselled on: Home treatment(s) Feeding and fluids When to return Immediately Follow-up

REFERRAL FACILITY Emergency Triage and Treatment (ETAT) Diagnosis Treatment Monitoring and followup

IMCI Key Family Practices

1. Breast feed infants exclusively for at least six (6) months. 2. Starting at six (6) months of age, feed children with freshly prepared energy and nutrient rich complementary foods, while continuing to breastfeed up to two (2) years or longer.

3. Ensure that children receive adequate amount of micro-nutrients ( Vitamin A and Iron, in particular ), either in their diet or through supplementation.

4.

Dispose of feces, including childrens feces safely; and wash hands after defecation, before preparing meals and before feeding children. Take children as scheduled to complete a full course of immunizations (BCG, OPV, DPT and Measles) before their first birthday. Protect children in malaria-endemic areas by ensuring that they sleep under insecticide-treated bednets.

5.

6.

7.

Promote mental and social development by responding to a childs needs for care and through talking, playing, and providing a stimulating environment. Continue to feed and offer more fluids including breast milk when they are sick. Give sick children appropriate home treatment for infections.

8.

9.

10. Recognize when sick children need treatment outside the home and seek care from appropriate providers.

11. Follow the health workers advice about treatment, follow-up and referral. 12. Ensure that every pregnant woman has adequate antenatal care.

GLOBAL UPDATES
Antibiotic treatment of severe and nonsevere pneumonia Low osmorality ORS and antibiotic treatment for bloody diarrhoea Treatment of ear infections Infant feeding Treatment of helminthiasis

ANTIBIOTIC TREATMENT OF SEVERE AND NON-SEVERE PNEUMONIA

NON-SEVERE PNEUMONIA
In low HIV prevalent countries three days of antibiotic therapy (oral amoxicillin and cotrimoxazole) should be used in children 2 months up up 5 years Where antimicrobial resistance to cotrimoxazole is high oral amoxicillin is the better choice Oral amixicillin should be used twice daily at a dose of 25 mg/kg per dose.

SEVERE PNEUMONIA
Children with wheeze and fast breathing and/or lower chest indrawing should be given a trial of rapid-acting inhaled bronchodilator before they are classified as pneumonia and prescribed antibiotics. Where referral is difficult and injection is not available, oral amoxicillin could be given to children with severe pneumonia.

VERY SEVERE PNEUMONIA

Injectable ampicillin plus injection gentamicin is a better choice than injectable chloramphenicol for very severe pneumonia in children 2-59 months of age

LOW OSMOLARITY AND ANTIBIOTIC TREATMENT FOR BLOODY DIARRHEA

LOW OSMOLARITY ORS

Countries should now use and manufacture the low osmolarity ORS for all children with diarrhoea but keep the same label to avoid confusion.

TREATMENT OF BLOODY DIARRHOEA

Ciprofloxacin is the most appropriate drug in place of nalidixic acid which leads to rapid development of resistance. Ciprofloxacin is given in a dose of 15 mg/kg two times per day for three days by mouth.

ZINC IN THE MANAGEMENT OF DIARRHOEA

Along with increased fluids and continued feeding, all children with diarrhoea should be given zinc supplementation for 10-14 days.

TREATMENT OF FEVER/MALARIA
Artemether-Lumefantrine (CoartemTM)
Artesunate (3 days) plus Amodiaquine Artesunate (3 days) plus SP in areas where SP efficacy remains high

SP plus amodiaquine in areas where efficacy of both amodiaquine and SP remain high.This is mainly limited to countries in West Africa.\

TREATMENT OF EAR INFECTIONS

Oral amoxicillin is a better choice for the management of acute ear infection in countries where antimicrobial resistance to co-trimoxazole is high. Chronic ear infection should be treated with topical quinolone ear drops for at least two weeks in addition to dry ear-wicking.

INFANT FEEDING

EXCLUSIVE BREASTFEEDING up to 6 months (180 days) of age

Breastfeed as often as the child wants, day and night, at least 8 times in 24 hours. Breastfeed when the child shows signs of hunger:beginning to fuss, sucking fingers, or moving the lips. Do not give other foods or fluids Only if the child is older than 4 months, and-appears hungry after breastfeeding, And-is not gaining weight adequately, add complementary foods (listed under 6 months up to 23 months). Give 1 or 2 tablespoons of these foods 1 or 2 times per day after breastfeeding.

COMPLEMENTARY FEEDING 6 MONTHS UP TO 23 MONTHS

Breastfeed as often as the child wants Give adequate servings of complementary foods: 3 times per day if breastfed, with 1-2 nutritious snacks, as desired, from 9 to 23 months. Give foods 5 times per day if not breastfed with 1 or 2 cups of milk. Give small chewable items to eat with fingers. Let the child try to feed self, but provide help.

MANAGEMENT OF SEVERE MALNUTRITION WHERE REFERRAL IS NOT POSSIBLE

Where a child is classified as having severe malnutrition and referral is not possible, the IMCI guideline should be adapted to include management at first-level facilities.

HIV AND INFANT FEEDING

In areas where HIV is a public health problem all women should be encouraged to receive HIV testing and counselling. If a mother is HIV-infected and replacement feeding is acceptable, feasible, affordable, sustainable and safe for her and her infant, avoidance of all breastfeeding is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life. The child of an HIV-infected mother who is not being breastfed should receive complementary foods as recommended above.

TREATMENT FOR HELMINTHIASIS

Helminth Infestations in children below 24 months
Albendazole and mebendazole can be safely used in children 12 months or older.

THANK YOU..