DR BIPSA SINGH

Asst. Prof. Paediatrics

Over the last 3 decades the annual number of deaths
among children less than 5 years old has decreased by
almost a third. However, this reduction has not been
evenly distributed throughout the world. Every year
more than 10 million children die in developing countries
before they reach their fifth birthday

Infant Mortality Rate (IMR) in India

continues to be high at 44/1000 live births and
Under Five Mortality Rate (U5MR) at 55/1000
live births.,odisha-u5mr-66(NFHS-III)
,odisha-imr 51 Neonatal mortality contributes
to over 64% of infant deaths and most of
these deaths occur during first week of life.
Odisha-37
 Many well-known prevention and treatment strategies like UIP,
Oral Rehydration and appropriate antibiotic therapy for
pneumonia have already proven effective for saving young lives.

 Even modest improvements in breastfeeding practices have

reduced childhood deaths.

 While each of these interventions has shown great success,

accumulating evidence suggests that a more integrated approach
to managing sick children is needed to achieve better outcomes.

 Child health programmes need to move beyond single diseases

to addressing the overall health and well being of the child.
 This is especially true for first-level health facilities
where examinations involve few instruments, little or
no laboratory tests, and no X-ray.
 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 the Integrated
Management of Childhood Illness (IMCI).
 This strategy has been adapted for India as Integrated
Management of Neonatal and Childhood Illness (IMNCI).

 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 take an evidence-based, syndromic

approach to case management that supports the rational,
effective and affordable use of drugs and diagnostic tools.
 An evidence-based syndromic approach can be used to
determine the:

 Health problem(s) the child may have;

 Severity of the child’s condition;

 Actions that can be taken to care for the child (e.g. refer the child
immediately, manage with available resources, or manage at
home).

 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.
The Principles of Integrated Care

 All sick young infant age upto 2months must be examined for
signs of “possible serious bacterial infenction” and all
children 2 months to 5 yrs must be examined for “general
denger signs”
 All sick children must be routinely assessed for major
symptoms (for young infants up to 2 months: diarrhoea; and
for children age 2 months up to 5 years: cough or difficult
breathing, diarrhoea, fever and ear problem). They must also
be routinely assessed for nutritional and immunization
status, feeding problems, and other potential problems.
The Principles of Integrated Care
 We will classify the child as per severity of condition.

 The classifications are colour coded: “pink” suggests

hospital referral or admission, “yellow” indicates initiation
of treatment, and “green” calls for home treatment

 IMNCI management procedures use a limited number of

essential drugs and encourage active participation of
caretakers in the treatment of children.
The Principles of Integrated Care

 An essential component of the IMNCI guidelines is the

counselling of caretakers about home care,
including counselling about feeding, fluids and when
to return to a health facility.
The charts describe the following steps:
 Assess the young infant or child

 Classify the illness

 Identify treatment

 Treat the infant or child

 Counsel the mother

 Give follow-up care

Assess and Classify the Sick Young
Infant Age upto 2 months
 Ask the mother what the young infant's problems are.
 Record what the mother tells you about the infant's
problems.
 Listen carefully to what the mother tells you. This will
show her that you are taking her concerns seriously.
 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.
 Determine if this is an initial or follow-up visit for this
problem
CLASSIFICATIONS

 POSSIBLE SERIOUS BACTERIAL INFECTION

 SEVERE JAUNDICE
 SEVERE DEHYDRATION
 SEVERE PERSISTENT DIARRHOEA
 SEVERE DYSENTERY
 NOT ABLE TO FEED - POSSIBLE SERIOUS
BACTERIAL INFECTION or
 SEVERE MALNUTRITION
ASK: LOOK, LISTEN, FEEL:
 Has the  Count the breaths in one

}
infant had minute.
YOUNG
convulsions? Repeat the count if elevated. INFANT
 Look for severe chest indrawing. MUST BE
 Look for nasal flaring. CALM
 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?
 Look for skin pustules. Are there 10 or
more skin pustules or a big boill?
Measure axillary temperature (if not possible, feel for
fever or low body temperature).
 See if the young infant is lethargic or
unconscious -
 Look at the young infant’s movements. Are they less
than normal?
 Look for jaundice
Are the palms and soles yellow ?
 MANAGEMENT OF THE SICK YOUNG INFANT AGE UP TO 2 MONTHS
Name: __ Swati __ Age: ___ 3 weeks Sex: M___ F___ Weight: ___3.0___ kg Temperature: _37.0_ °C
ASK: What are the infant’s problems? ____Skin rash ______ Initial visit? _____ Follow-up Visit?______
ASSESS (Circle all sings present)
CLASSIFY

CHECK FOR POSSIBLE BACTERIAL INFECTION / JAUNDICE

Has the infant had convulsions? Count the breaths in one minute. ___55____ breaths per
minute. Repeat if elevated ________ Fast breathing? Local
Look for severe chest indrawing. Bacterial
Look for nasal flaring. Infection
Look and listen for grunting.
Look and feel for bulging fontanelle.
Look for pus draining from the ear.
Look at umbilicus. Is it red or draining pus?
Look for skin pustules. Are there 10 or more skin pustules
or a big boil?
Measure axillary temperature (if not possible, feel for fever
or low body temperature): 37.5°C or more (or feels
hot)?
Less than 35.5°C?
Less than 36.5°C but above 35.4°C (or
feels cold to touch)?
See if young infant is lethargic or unconscious.
Look at young infant’s movements. Less than normal?
Look for jaundice. Are the palms and soles yellow?
 SIGNS CLASSIF
Y AS IDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print)

 Convulsions or
 Fast breathing (60 breaths per minute POSSIBLE  Give first dose of intramuscular ampicillin and
or more) or SERIOUS
BACTERIAL gentamicin
 Severe chest indrawing or INFECTION  Treat to prevent low blood sugar

 Nasal flaring or  Warm the young infant by skin to skin contact if

 Grunting or  temperature less than 36.5oC (or feels cold to
 touch) while arranging referral
 Bulging fontanelle or
 Advise mother how to keep the young infant warm on
 10 or more skin pustules or a big the way to the hospital
boil or
 If axillary temperature 37.5oC or
 Refer URGENTLY to hospital#
 above (or feels hot to touch) or
temperature less than 35.5oC (or feels
cold to touch) or

 Lethargic or unconscious or

 Less than normal movements

 Umbilicus red or draining pus or LOCAL  Give amoxycillin for 5 days.

 Pus discharge from ear or BACTERIAL  Teach mother to treat local infections at home.
 < 10 skin pustules INFECTION
 Follow up in 2 days
 Palms and soles yellow or SEVERE  Treat to prevent low blood sugar
 Age < 24 hours or JAUNDICE  Warm the young infant by skin to skin contact if
 Age 14 days or more
 temperature less than 36.5 oC (or feels cold to touch)
 while arranging referral
 Advise mother how to keep the young infant warm on
 the way to the hospital
 Refer URGENTLY to hospital#

 Palms and soles not yellow JAUNDICE  Advise mother to give home care for the young infant

 Advise mother when to return immediately

 Follow up in 2 days

 Temperature between 35.5- LOW BODY  Warm the young infant using Skin to Skin
contact for one hour and REASSESS
36.4oC TEMPERATURE
 Treat to prevent low blood sugar
A classification in a Red row needs urgent attention
and referral or admission for inpatient care. This is a
severe classification.
 A classification in a yellow row means that the young
infant or the child needs an appropriate antibiotic or other
treatment. The treatment includes teaching the mother how
to give the oral drugs or to treat local infections at home.
The doctor advises her about caring for the young infant or
child at home and when she should return.
 A classification in a green row means the young
infant or child does not need specific medical treatment
such as antibiotics. The doctor teaches the mother how to
care for her young infant or child at home. For example,
you might advise her on feeding her sick young infant or
child or giving fluid for diarrhoea.
Two of the following signs:
 Lethargic or unconscious
 Sunken eyes
 Skin goes back very slowly
Two of the following signs:
 Restless, irritable
 Sunken eyes
 Skin goes back slowly
 Not enough signs to classify as some or
severe dehydration
 If infant has low weight or another severe classification:
SEVERE DEHYDRATION  Give first dose of intramuscular ampicillin and gentamicin
 Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
 Advise mother to continue breast feeding
 Advise mother to keep the young infant warm on the way to the hospital
OR
 If infant does not have low weight or any other severe classification:
 Give fluid for severe dehydration (Plan C) and then refer to hospital after rehydration
 If infant has low weight or another severe classification:
SOME DEHYDRATION  Give first dose of intramuscular ampicillin and gentamicin
 Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
 Advise mother to continue breast feeding
 Advise mother to keep the young infant warm on the way to the hospital
 If infant does not have low weight or another severe classification:
 Give fluids for some dehydration (Plan B)
 Advise mother when to return immediately
 Follow up in 2 days
NO DEHYDRATION  Give fluids to treat diarrhea at home (Plan A)
 Advise mother when to return immediately
 Follow up in 5 days if not improving
 Blood in the stools Give first dose of intramuscular ampicillin and gentamicin if the young infant has
SEVERE
low weight, dehydration or another severe classification.
DYSENTERY

Treat to prevent low blood sugar.

Advise how to keep infant warm on the way to the hospital.

Refer to hospital. #

 Diarrhea lasting 14 days or more Give first dose of intramuscular ampicillin and gentamicin if the young infant has low
SEVERE
weight, dehydration or another severe classification.
PERSISTENT
DIARRHEA Treat to prevent low blood sugar.

Advise how to keep infant warm on the way to the hospital.

Refer to hospital. #