IMNCI

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Integrated Management of Neonatal and Childhood Illness

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IMNCI:

IMNCI Integrated Management of Neonatal and Childhood Illness Dr. Vijaysinh Bhatlawande Dept. of Pediatrics, Dr. Jagdale Mama Hospital, Barshi Dr. Sumit Thakur MD

1.1 THE INEQUITIES OF CHILD HEALTH:

1.1 THE INEQUITIES OF CHILD HEALTH Over the last 3 decades the annual number of deaths among children less than 5 years of age has decreased by almost a third. However, this reduction has not been evenly distributed throughout the world.

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Every year more than 10 million children die in developing countries before they reach their fifth birthday. Seven in 10 of these deaths are due to acute respiratory infections (mostly pneumonia), diarrhoea , measles, malaria, or malnutrition - and often to a combination of these illnesses

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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. This assumption makes a strong case for introducing new strategies to significantly reduce child mortality and improve child health and development..

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Infant and childhood mortality are sensitive indicators of inequity and poverty. It is no surprise to find that the children who are most commonly and severely ill, who are malnourished and who are most likely to die of their illness belong to the most vulnerable and underprivileged populations of low -income countries.

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Improvements in child health are not necessarily dependent on the use of sophisticated and expensive technologies.

1.2 RATIONALE FOR AN INTEGRATED EVIDENCE-BASED SYNDROMIC APPROACH TO CASE MANAGEMENT:

1.2 RATIONALE FOR AN INTEGRATED EVIDENCE-BASED SYNDROMIC APPROACH TO CASE MANAGEMENT An integrated approach is needed to manage sick children to achieve better outcomes. Child health programmes need to move beyond tackling single diseases in order to address the overall health and well-being of the child.

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During the mid-1990s, The World Health Organization ( WHO ), in collaboration with UNICEF and many other agencies, institutions and individuals, responded to this challenge by developing a strategy known as, Integrated Management of Childhood Illness(IMCI).

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An integrated approach is needed to manage sick children to achieve better outcomes. Child health programmes need to move beyond tackling single diseases in order to address the overall health and well-being of the child. Improvements in child health are not necessarily dependent on the use of sophisticated and expensive technologies.

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IMCI strategy curative care, aspects of nutrition, immunization, disease prevention and health promotion. The objectives to reduce death frequency and severity of illness and disability, to improved growth and development. This strategy has been expanded in India to include all neonates and renamed as ‘Integrated Management of Neonatal and Childhood Illness (IMNCI)’.

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The IMNCI clinical guidelines target children less than 5 years old — the age group that bears the highest burden of deaths from common childhood diseases.

The guidelines represents:

The guidelines represents Evidence-based, syndromic approach to case management 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 decision-making.

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In situations where laboratory support and clinical resources are limited, the syndromic approach is a more realistic and cost-effective way to manage patients. Careful and systematic assessment of common symptoms and well-selected clinical signs provides sufficient information to guide rational and effective actions.

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An evidence-based syndromic approach can be used to determine the: health problem(s) the child may have; severity of the child’s 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).

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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.

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Parents if correctly informed and counselled , can play an important role in improving the health status of their children by following the advice given by a health care provider, by applying appropriate feeding practices and by bringing sick children to a health facility as soon as symptoms arise.

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Careful and systematic assessment of common symptoms and well selected specific clinical signs provide sufficient information to guide rational and effective actions.

1.3 COMPONENTS OF THE INTEGRATED APPROACH:

1.3 COMPONENTS OF THE INTEGRATED APPROACH The strategy includes three main components: Improvements in the case-management skills of health staff through the provision of locally-adapted guidelines on IMNCI and activities to promote their use; Improvements in the overall health system required for effective management of neonatal and childhood illness; Improvements in family and community health care practices.

1.4 THE PRINCIPLES OF INTEGRATED CARE:

1.4 THE PRINCIPLES OF INTEGRATED CARE Depending on a child’s age, various clinical signs and symptoms differ in their degrees of reliability and diagnostic value and importance. Therefore, the IMNCI guidelines recommend case management procedures based on two age categories: Young infants age up to 2 months Children age 2 months up to 5 years

The IMNCI guidelines are based on the following principles::

The IMNCI guidelines are based on the following principles: All sick young infants up to 2 months of age must be assessed 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 be examined 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.

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All sick young infants and children 2 months up to 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. These signs were selected considering the conditions and realities of first-level health facilities.

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5. A combination of individual signs leads to an infant’s or a child’s classification(s) rather than a diagnosis. Classification(s) indicate the severity of condition(s). They call for specific actions based on whether the infant or child should be urgently referred to a higher level of care, (b) requires specific treatments (such as antibiotics or antimalarial treatment), or (c) may be safely managed at home. The classifications are colour coded : “pink” suggests hospital referral or admission, “yellow” indicates initiation of specific treatment, “green” calls for home management.

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The IMNCI guidelines address most, but not all, of the major reasons a sick infant or child is brought to a clinic. An infant or child returning with chronic problems or less common illnesses may require special care. The guidelines do not describe the management of trauma or other acute emergencies due to accidents or injuries. They also do not cover care at birth. 7. IMNCI management procedures use a limited number of essential drugs and encourage active participation of caretakers in the treatment of infants and children.

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AN ESSENTIAL COMPONENT OF THE IMNCI GUIDELINES IS THE 1.COUNSELLING OF CARETAKERS 2. ABOUT HOME CARE, 3. INCLUDING COUNSELLING ABOUT FEEDING, FLUIDS AND 4. WHEN TO RETURN TO A HEALTH FACILITY.

1.5 THE IMNCI CASE MANAGEMENT PROCESS:

1.5 THE IMNCI CASE MANAGEMENT PROCESS Summary of the Integrated Case Management Process

The case management of a sick child brought to a first level health facility includes a number of important elements in young infants up to 2 months of age and children 2 months up to 5 years respectively.:

The case management of a sick child brought to a first level health facility includes a number of important elements in young infants up to 2 months of age and children 2 months up to 5 years respectively . Outpatient Health Facility Assessment; Classification and identification of treatment; Referral, treatment or counselling of the child’s caretaker (depending on the classification(s) identified); Follow-up care.

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Referral Health Facility Emergency triage assessment and treatment (ETAT); Diagnosis, treatment and monitoring of patient progress. Appropriate Home Management Teaching mothers or other caretakers how to give oral drugs and treat local infections at home; Counselling mothers or other caretakers about food (feeding recommendations, feeding problems); fluids; when to return to the health facility; and the mother’s own health.

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If the child is not yet two months of age, the child is considered a young infant. Children who are 5 years of age or older, i.e. have had their fifth birthday, should not be managed according to IMNCI charts.

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IMNCI Case Management in the Outpatient Health Facility, First-level Referral Facility and at Home For the Sick Young Infant up to 2 Months of Age

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IMNCI Case Management in the Outpatient Health Facility, First-level Referral Facility and at Home For the Sick Child From Age 2 Months up to 5 Years

CHAPTER 2:

CHAPTER 2 OUTPATIENT MANAGEMENT OF YOUNG INFANTS UP TO 2 MONTHS OF AGE

ASSESSMENT OF SICK YOUNG INFANTS:

ASSESSMENT OF SICK YOUNG INFANTS

CHECKING FOR POSSIBLE BACTERIAL INFECTION:

CHECKING FOR POSSIBLE BACTERIAL INFECTION

CHECKING FOR POSSIBLE JAUNDICE:

CHECKING FOR POSSIBLE JAUNDICE

DIARRHOEA:

DIARRHOEA

CHECKING FOR FEEDING PROBLEMS & MALNUTRITION:

CHECKING FOR FEEDING PROBLEMS & MALNUTRITION

TREATMENT OF SICK YOUNG INFANTS:

TREATMENT OF SICK YOUNG INFANTS

TREATMENT OF SICK YOUNG INFANTS:

TREATMENT OF SICK YOUNG INFANTS ORAL DRUGS TREATMENT OF LOCAL INFECTIONS COUNSELLING A MOTHER OR CARETAKER Counselling about Feeding Problems Advise when to return IMMEDIATELY FOR FOLLOW-UP VISIT NEXT WELL-CHILD VISIT FOLLOW-UP CARE COUNSEL THE MOTHER ABOUT HER OWN HEALTH

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OUTPATIENT MANAGEMENT OF CHILDREN AGE 2 MONTHS UP TO 5 YEARS

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Asking the mother about the child's problem. Checking for general danger signs. Asking the mother about the four main symptoms: cough or difficult breathing Diarrhoea Fever ear problem .

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3. When a main symptom is present: - assessing the child further for signs related to the main symptoms - classifying the illness according to the signs which are present or absent. 4. Checking for signs of malnutrition and anaemia and classifying the child's nutritional status. 5. Checking the child's immunization status and deciding if the child needs any immunizations today. 6. Assessing any other problems.

COUGH OR DIFFICULT BREATHING:

COUGH OR DIFFICULT BREATHING Clinical Assessment Three key clinical signs Respiratory rate, Lower chest wall indrawing , Stridor

Classification of Cough or Difficult Breathing:

Classification of Cough or Difficult Breathing

Classification of Dehydration:

Classification of Dehydration

Classification of Fever:

Classification of Fever

Classification of Ear Problems:

Classification of Ear Problems

CLASSIFICATION OF NUTRITIONAL STATUS:

CLASSIFICATION OF NUTRITIONAL STATUS

CLASSIFICATION OF ANAEMIA:

CLASSIFICATION OF ANAEMIA Severe palmar pallor SEVERE ANAEMIA Some palmar pallor ANAEMIA No palmar pallor NO ANAEMIA

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ASSESSING THE CHILD'S FEEDING

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CHECKING IMMUNIZATION, VITAMIN A & FOLIC ACID SUPPLEMENTATION STATUS

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ASSESSING OTHER PROBLEMS

Urgent Pre-referral Treatments for Children Age 2 Months Up To 5 Years :

Urgent Pre-referral Treatments for Children Age 2 Months Up To 5 Years Appropriate antibiotic Quinine (for severe malaria) Vitamin A Prevention of hypoglycemia with breastmilk or sugar water Oral antimalarial Paracetamol for high fever (38.5°C or above) or pain Tetracycline eye ointment (if clouding of the cornea or pus draining from eye) ORS solution so that the mother can give frequent sips on the way to the hospital

TREATMENT IN OUTPATIENT CLINICS:

TREATMENT IN OUTPATIENT CLINICS ORAL DRUGS Oral antibiotics Oral antimalarials Paracetamol Iron & folic Acid Vitamin A Safe remedy for cough and cold TREATMENT OF LOCAL INFECTIONS Treat eye infection with tetracycline eye ointment; Dry the ear by wicking to treat ear infection; Treat mouth ulcers with gentian violet; Soothe the throat and relieve the cough with a safe remedy.

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COUNSELLING A MOTHER OR CARETAKER FOLLOW-UP CARE

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Follow-up visits are recommended for sick children classified as having : Pneumonia Diarrhoea Dysentery Malaria, if fever persists Fever – Malaria Unlikely, if fever persists NEXT WELL-CHILD VISIT Measles with eye or mouth complications Persistent diarrhoea Ear infection Feeding problem Anaemia Very low weight for age

PRINCIPLES OF MANAGEMENT OF SICK CHILDREN IN A SMALL HOSPITAL:

PRINCIPLES OF MANAGEMENT OF SICK CHILDREN IN A SMALL HOSPITAL Those with emergency signs who require immediate emergency treatment: obstructed breathing, severe respiratory distress, central cyanosis, signs of shock, coma, convulsions, or signs of severe dehydration.

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Those with priority signs who should be given priority while waiting in the queue so they can be assessed and treated without delay: visible severe wasting, oedema of both feet, severe palmar pallor, any sick young infant (less than 2 months), lethargy, continual irritability and restlessness, major burns, any respiratory distress, or urgent referral note from another health facility. Non-urgent cases that have neither emergency nor priority signs.

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Thanks……