Causes of 10.

5 million deaths among children

< 5 in developing countries, 1999

Pneumonia
19%

Integrated
One in
every two
child deaths
in perinatal

Management of developing
countries
are due to
20% Malnutrition

54%
Diarrhoea

Childhood Illness just five 15%

Others 28%
infectious
diseases
and
malnutrition Measles
8%
HIV/AIDS Malaria
3% 7%
Integrated Management of Childhood Illness Source: EIP/WHO, 1999 data
WHO Regional Office for the Western Pacific/ Child Health

Important Elements
for Improving Child Health

• Improve case management of sick children

• Improve nutrition
• Ensure immunization
• Prevent injuries
• Prevent other diseases
• Improve psychosocial support and stimulation

Too many different pieces… IMCI brings them all together

Appropriate
Case Care seeking Anemia
management IMPROVEMENT OF HEALTH SYSTEM
Home
Nutrition HIV/AIDS care
Drug
Use IMPROVEMENT OF CASE MANAGEMENT
New born
Malaria care
Child Follow-up FAMILY AND COMMUNITY PRACTICES
rights
Health Safe and
system Mothers Supportive CHILD RIGHTS
Communication
health Environment

1
 IMCI Case Management
At the start of a sick child
(2 months to 5 years) consultation Classification
Focused Assessment
Need to Refer
• Ask the mother what the child’s Danger signs
Main Symptoms
problems are. Nutritional status Specific treatment
Immunization status
• Determine if this is an initial or follow- Other problems Home
up visit for this problem. management

Counsel & Follow-up Treatment

Counsel caretakers Identify treatment

Follow-up Treat
p. 2

Check for general danger signs

Ask about the main symptoms
Ask:
• Not able to drink or breastfeed,
• Cough or difficulty in breathing
• Vomits everything,
• Convulsions, or • Diarrhea
Look: • Fever
• Abnormally sleepy or difficult
• Ear problem
to awaken

Need to Refer
(except in severe dehydration) p. 2 p. 2

Cough or difficulty in breathing  Any general danger sign or

 Chest indrawing or
 Stridor
Ask:
• For how long?
Look: SEVERE PNEUMONIA OR
• Count RR VERY SEVERE DISEASE
• Chest indrawing The child
must be calm.
• Stridor
 1st dose of antibiotic
 Vitamin A
 Breastfeeding/sugar water
p. 2  URGENT REFERRAL

2

After trial  no improvement
PNEUMONIA
 Antibiotic for 3 days
 Relieve cough with safe remedy
 Advise mother on danger signs
 Follow up in 2 days
Diarrhea: Classify
For dehydration
Persistent diarrhea
Blood in the stool
p. 3
 Wheeze,
 Fast breathing
2 – 12 months old: ≥ 50/minute
1 year or older: ≥ 40/minute, OR
 Lower chest indrawing
 Trial of rapid-acting inhaled
bronchodilator (3 cycles, 15-20
minutes apart)
No signs of pneumonia
or a very severe disease
NO PNEUMONIA: COUGH OR COLD
 If cough ≥ 30 days
 refer to hospital for assessment
 Relieve cough with safe remedy
 Advise mother on danger signs
 Follow up in 5 days if no improvement
Classify for dehydration
2 or more of the following:
 Abnormally sleepy/difficult to wake
 Sunken eyes
 Not able to feed/drinking poorly
 Skin pinch goes back very slowly
p. 3
3
 Classify for dehydration

2 or more of the following:

 Abnormally sleepy/difficult to wake
 Sunken eyes
 Not able to feed/drinking poorly
 Skin pinch goes back very slowly

SEVERE DEHYDRATION Plan C

p. 3

Plan C: To treat dehydration quickly Plan C: To treat dehydration quickly

IV fluid: LRS 100 ml/kg body weight Oresol/NGT

(in 6 hrs for infants; 3 hrs for children)
NO
NO
Oresol p.o.
IV treatment within 30 minutes
NO
NO

URGENT REFERRAL
Oresol/NGT p. 15 p. 15

Classify for dehydration

Plan B: Treat some dehydration with ORS

2 or more of the following: Determine the amount (in ml) of Oresol

 Restless, irritable to be given in 4 hours
 Sunken eyes = weight of the child (in kg) X 75, or
 Drinks eagerly, very thirsty if weight is unknown, use this chart.
 Skin pinch goes back slowly
Age < 4 mos 4-12 mos
Amount 200-400 400-700
SOME DEHYDRATION Plan B
p. 3 p. 14

4
Plan B: Treat some dehydration with ORS Plan B: Treat some dehydration with ORS

Determine the amount (in ml) of Oresol  Show the mother how to give Oresol to
to be given in 4 hours the child: frequent sips from a cup
= weight of the child (in kg) X 75, or  If the child vomits, wait for 10 minutes.
if weight is unknown, use this chart. Then continue, but more slowly.
 Continue breastfeeding if the child
wants to breastfeed.
Age 12 mos-2 yrs 2-5 yrs
Amount 700-900 900-1400

p. 14 p. 14

Classify for dehydration

Plan B: Treat some dehydration with ORS

After 4 hours:
 Reassess the child & classify for
Not enough signs to classify as
dehydration. SEVERE DEHYDRATION or
 Select appropriate plan. SOME DEHYDRATION
 Begin feeding the child in the health
center.

NO DEHYDRATION Plan A
p. 14 p. 3

Plan A: Treat diarrhea at home

Reformulated Oresol
 Give extra fluid.

Up to 2 yrs 50 – 100 ml after each LBM • Less electrolytes (75 mEq/L) and
glucose (75 mmol/L)
2 -4 yrs 100 – 200 ml after each LBM
• Lower osmolarity (total = 245
 Continue feeding. mOsm/L)

 Know when to return.

 Increased absorption of water &
 Zinc 20 mg tab OD for 10-14 days: electrolytes
< 6 mos ½ tab
≥ 6 mos 1 tab p. 14

5
 Persistent diarrhea: 14 days or more Persistent diarrhea: 14 days or more

+ Dehydration=severe persistent diarrhea No dehydration=persistent diarrhea

• Advise regarding feeding

• Treat dehydration
• Give multivitamin &
• Give Vitamin A mineral (including zinc)
• Refer to hospital supplements x 14 days
• Follow up in 5 days

p. 3 p. 3

Fever: (history/temperature 37.5°C or above)

Blood in the stool = dysentery

Malaria risk?

• Oral antibiotic for shigella for

3 days Measles now or w/in last 3 mos
• Follow up in 2 days

Dengue risk?

p. 3 p. 4

Fever: Ask about malaria risk Malaria risk +

• Residing in endemic area?

OR:
• Travel & overnight • Blood smear
stay in endemic area, or w/in past • Ask: Duration of fever?
• Blood transfusion 6 mos
Present everyday?
• Look: Stiff neck
Runny nose
Other signs of measles

6
 Malaria risk + Malaria risk +, blood smear +
any general danger sign or stiff neck No runny nose, no measles

Malaria
Very severe febrile disease/malaria

• Oral antimalarial
• Quinine (under med. supervision) • Paracetamol
• 1st dose of antibiotic, Paracetamol • Follow up in 2 days
• Urgent referral • > 7 days fever  hospital for
assessment

No malaria risk Measles now or w/in last 3 mos

Any general danger sign or stiff neck Clouding of cornea or
Deep or extensive mouth ulcers

Very severe febrile disease

Severe complicated measles

• 1st dose of antibiotic, Paracetamol

• 1st dose of antibiotic, Vitamin A
• Urgent referral
• Urgent referral

Measles now or w/in last 3 mos Measles now or w/in last 3 mos
Pus draining from the eye or No other signs
Mouth ulcers

Measles with eye or Measles

Mouth complications

• Vitamin A
Vitamin A
• Tetracycline eye ointment
• Gentian violet
• Follow up in 2 days

7
 If there is Dengue risk
Bleeding gums, nose, in vomitus or
stools
Black vomitus or stools
Persistent abdominal pain
Persistent vomiting
Skin petechiae
Slow capillary refill
No signs, but fever > 3 days 
Tourniquet test
Any of the danger signs
or + tourniquet test
Severe Dengue hemorrhagic fever
• If skin petechiae, persistent abdominal
pain or vomiting, or + tourniquet test
only signs, give ORS
• Any other signs of bleeding  Plan C
• Urgent referral
• Do not give aspirin

Ear problem:
tender swelling behind ear

Mastoiditis

• 1st dose of antibiotic

• Paracetamol for pain
• Urgent referral

Ear discharge < 14 days or

Ear discharge for 14 days or more
Ear pain

Chronic ear infection

Acute ear infection

• Antibiotic (Amoxicillin) for 5 days • Quinolone ear drops x 2 wks

• Paracetamol for pain • Wicking
• Wicking • Follow up in 5 days
• Follow up in 5 days

8
 Visible severe wasting or
Edema on both feet or
Severe palmar pallor

Severe malnutrition or
severe anemia

• Vitamin A
• Urgent referral

Some palmar pallor or

Very low weight for age

Anemia or very low weight for age

• Assess for feeding problem

• Pallor: iron & Albendazole
• Wt for age very low: Vitamin A