IMCI

Integrated Management of Childhood Illness

IMCI Process

◦A case mgt process for a first-

level facility such as clinic, health
center, or the outpatient dept of
the hospital
Two Objectives of IMCI

◦1. Significantly reduce global

mortality and morbidity
associated with major causes of
disease in children.
◦2. To contribute to healthy growth
and development of children.
Three Components of IMCI

1. Upgrading the case

management and counselling
skills of health care providers.
2. Strengthening the health system
for effective management of
childhood illness.
3. Improving family and
community practices related to
child health and nutrition.
Elements of IMCI
◦Assess
◦Classify
◦Identify
◦Treatment
◦Counsel
◦Give Follow-up
Principles of IMCI
1. All sick children must be assessed
for major symptoms.
-for children 2mos to 5 years:
cough,fever,diff. of breathing,
diarrhrea and ear problem.
-for age 1 week to 2 mos:
bacterial infection and
diarrhea.
2. Only limited number of
carefully-selected clinical signs
are used, based on evidence of
their sensitivity and specificity to
detect disease.
3. A combination of individual signs
leads to a child’s classification rather
than a diagnosis.
4.The IMCI guidelines address most,
but not all the major reasons a sick
child is brought to the clinic.
5. IMCI management procedures
use a limited number of essential
drugs and encourage active
participation of caretakers in the
treatment of children.
6.An essential component of IMCI
guidelines is the counseling of
caretakers about home
management.
IMCI Case Management Process

OUTPATIENT HEALTH FACILITY

Check for Danger Signs

◦ Convulsion
◦ Lethargy
◦ Inability to drink
◦ Vomiting
 Assess Main Symptom
◦Cough
◦Diarrhea
◦Fever
◦Ear problems
◦Assess Nutrition and
Immunization Status and
Potential Feeding Problems
 Check for other Problems
Classify Condition and Identify
Treatment Actions According to color-
coded treatment
Pink-Urgent Referral Yellow-Outpatient Green-Home
Management
Health Facility

Outpatient Health Outpatient Health Home

Facility Facility

Pre-referral treatment Treat local infection Caretaker is

Advise parents Give oral drugs counseled on:
Refer Child Advise and teach Refer child
caretaker Home treatments
Follow-up Feeding and fluids
Referral Facility When to return
Emergency triage immediately
Diagnosis Follow-up
Treatment
Monitoring
Assessment

◦Sick young infant aged 1 week to 2

months

◦Sick child aged 2 months to 5 years

2 mos to 5 years
Check for general danger
signs
◦The child is not able to drink or
breastfeed
◦The child vomits everything
◦The child has convulsion
◦The child is abnormally sleepy or
difficult to awaken
◦A child with any general danger
signs needs URGENT attention,
complete the assessment and any
pre-referral treatment immediately
so referral is not delayed
A child with any general
danger sign

◦Make sure the child is referred after

the first dose of antibiotic and other
urgent treatments
Ask about the Main Symptoms

◦ Cough or DOB
◦ Diarrhea
◦ Fever
◦ Ear Problem
Cough or Difficult Breathing

◦If yes: For how long?

◦Look, Listen:
- Fast Breathing
- Chest Indrawing
- Stridor in a calm child
Fast breathing

◦2 mos to 12 months: 50 breaths/min

or more
◦12 mos to 5 years: 40 breathes/min or
more
Chest indrawing

◦Is when the lower chest wall (lower

ribs) goes in as the child breathes in
stridor

◦A harsh noise when the child

breathes IN
◦Swelling of the larynx , trachea or
epiglottis.
Classify cough or DOB
◦ SIGNS
◦ Any gen. danger sign
◦ Chest indrawing
◦ Stridor in a calm child
CLASSIFY AS: SEVERE PNEUMONIA OR VERY
SEVERE DISEASE
◦Fast Breathing
CLASSIFY AS : PNUEMONIA
◦No signs of pneumonia or very severe
disease
CALSSIFY AS: NO PNUEMONIA; COUGH
OR COLD
Treatment for severe Pneumonia
or very severe disease

◦First dose of antibiotic

◦Vitamin A
◦Prevent low blood sugar
◦Refer urgently to the hospital
4 steps to refer a child to the
hospital
1. Explain to the mother the need for
referral and get her agreement to
take the child.
2. Calm the mother’s fears and help
resolve any problems.
3. Write a referral note for the
mother to take with her to the
hospital.
4. Give the mother supplies and
instructions needed to care for her
child on the way to the hospital.
 September 7,2021

Sample of Referral Note

Urgent Referral to Escalante District Hospital
Mike Lunto , age 18 months
Referred for: Severe dehydration
Severe malnutrition
No cough, no chest indrawing
Treatment given at Barangay Health
Center
ORS mother to give sips on the way to the
hospital
Encar Zubiri,RN
IMCI Practitioner
Brgy. Malasibog HC
Steps in teaching mothers for home
care

◦Give information
◦Show an example
◦Let her practice
skills
◦Ask questions and Listen
◦Praise
◦Advise
◦Check
(ALPAC)
Situation:
◦ Redin is 6 mos old. He weighs 5.5 kg. His
temp is 38 C. His mother says he has been
coughing for 2 days now. His mother says
that he is able to breastfeed. He has not
vomited during this illness. He has not have
convulsions. Alden is not abnormally sleepy
or difficult to awaken. The health worker
counts 58 breaths per minute. He does not
see any chest indrawing nor hear stridor.
How do you classify Alden’s condition
based on IMCI standard?
◦ A. Redin is having severe pneumonia or
very severe disease
◦ B. Redin is having pneumonia.
◦ C. Inform the mother that Redin is having
cough or cold and no pneumonia
◦ D. Classify Alden under the green row for
treatment
Sign: Fast breathing
Classify as: Pneumonia
Tx: - Give an appropriate Antibiotic for
5 days.
- Soothe the throat and relieve the
cough with safe remedy.
- Advise the mother when to return
immediately
- Follow-up in 2 days
 Assess for Diarrhea

◦How long?
◦Blood in the stool
◦Signs of DHN
◦ Look and feel for the following signs:
◦ Abnormally sleepy or difficult to awaken
◦ Restless and irritable
◦ Sunken eyes
◦ Is the child not able to drink or drinking
poorly?
◦ Drinking eagerly, thirsty?
◦ PINCH the skin of the abdomen. Does it goes
back:
◦ Very slowly
◦ Slowly
◦ Immediately
Classify Diarrhea

◦ Persistent diarrhea- 14 days or more; no

DHN
◦ Severe Persistent diarrhea- 14 days or
more and has DHN
◦ Dysentery: blood in the stool
Classify Dehydration

◦ Two of the following signs:

◦ Abnormally sleepy or difficult to awaken
◦ Sunken eyes
◦ Not able to drink or drinking poorly
◦ Skin pinch goes back slowly
CLASSIFY: SEVERE DEHYDRATION
◦ Two of the following signs:
◦ Restless and irritable
◦ Sunken eyes
◦ Drinks eagerly, thirstily
◦ Skin pinch goes back slowly
◦ CLASSIFY: SOME DEHYDRATION
◦ Not enough signs to classify as having some
or severe dehydration.
◦ CLASSIFY: NO DEHYDRATION
Situation

◦ Miriam has had diarrhea for 5 days. She has

no blood in the stool. Her eyes are sunken.
The health worker offers her some water
and she drinks eagerly. When the health
worker pinches her skin on her abdomen, it
goes back slowly.
◦A. Miriam has severe dehydration.
◦B. Miriam has some dehydration.
◦C. Miriam has no dehydration.
◦D. Miriam has severe persistent
diarrhea.
◦ Answer B
◦ Some Dehydration
◦ Tx: Give ORS, zinc supplements and food
◦ If with other severe classification Refer
urgently
◦ Continue breastfeeding.
◦ Follow up in 5 days if not improving.
ASSESS AND CLASSIFY FEVER

◦Malaria is caused by parasites in the

blood called “plasmodium
falciparum”. Transmitted through the
bite of anopheles mosquitoes.
Category of Provinces

◦ Category A- 1,000 cases in the last 10 years

Agusan del Sur and Norte
Basilan
Cagayan
Davao del Sur
Palawan
Zamboanga del Sur
◦ Category B:100-1,000 per year
Abra Rizal
Bulacan Tarlac
Bataan
North cotabato
Nueva Ecija
Romblon
◦Category C: significant decrease in
the last 5 years
Albay Negros Occ.
Antique Negros Or.
Batanes Samar
Batangas
Cavite
◦Category D: malaria free
Aklan Siquijor
Biliran
Camiguin
Capiz
Cebu
Guimaras
leyte
◦ Measles caused by a virus and damages
the immune system for many weeks.
◦ Dengue Hemorrhagic Fever caused by
Aedes egypti mosquitoes which causes
bleeding.
Assess fever

◦ The child has history of fever

◦ The child feels hot
◦ The child has axillary temp of 37.5C or
above
◦ Decide malaria risk; if there is risk take a
blood smear and examine.
◦ How long is the fever present?
◦ Has the child had measles within the last 3
mos?
◦ Look and feel for stiff neck.
◦ Look for runny nose.
◦ Look for signs suggesting measles.
◦ Generalized Rash
◦ Cough, runny nose or red eyes
◦ Look for mouth ulcers
◦ Look for pus draining from the eye
◦ Look for clouding of cornea
◦ Assess Dengue
◦ Has the child had persistent abdominal
pain?
◦ Has the child had persistent vomiting?
◦ Look and feel for Signs of Bleeding and
Shock
◦ Bleeding manifestations:
◦ Bleeding from the nose and gums.
◦ Skin petechiae
◦ Look and Feel for Signs of Shock:
◦ Cold Clammy skin
◦ Slow Capillary Refill
◦ Torniquet Test
*Any general danger Very Severe Febrile
sign Disease/Malaria
*Stiff neck
*Blood Smear (+)
If blood smear not
done: Malaria
No runny nose, and
No measles, and
No other cause of fever

Blood smear(-)
Runny nose Fever:
Malaria
Measles
Unlikely
Other causes of
fever
◦ No malaria risk:
◦ VERY SEVERE FEBRILE DISEASE
◦ FEVER: NO MALARIA
Any general danger VERY SEVERE FEBRILE Give 1st dose of an
sign or stiff neck DISEASE appropriate antibiotic
Tx the child to prevent
low blood sugar
Give 1 dose of
paracetamol
Refer urgently

No sign of very severe FEVER Give 1 dose of

febrile disease NO MALARIA paracetamol
Advise mother when to
return
Tx other causes of fever
Classify Measles
◦ SEVERE COMPLICATED MEASLES
◦ MEASLES WITH EYE OR MOUTH COMPLICATIONS
◦ MEASLES
Situation

◦Mae is 48 months old.She weighs

12kgs. Her axillary temperature is 37C.
Her mother is worried because of the
rashes that appeared on her
extremities.
◦When the health worker checked for
general danger signs, Mae is
◦Able to drink. She is not vomiting, has
had no convulsions, and is not
abnormally sleepy or difficult to
awaken. Mae does not have cough
and does not have diarrhea.
◦The health worker asked if Mae had
been feeling hot.
◦Her mother said that Mae had
been hot for 3 days.Her eyes are
red. There is no malaria risk. She
does not have stiff neck or runny
nose. No pus draining from her
eye and no clouding of the
cornea. No cases of dengue in
their are
◦ A. Mae is having severe complicated
measles.
◦ B. Mae has measles with eye or mouth
complications.
◦ C. Mae has measles.
◦ D. Mae is having severe febrile disease.
◦Answer: C
◦Mae is having measles as evidenced
by rashes and fever but with no
complications.
Situation:
Steven is 15 months old brought by his
mother to the health center due to
agonizing ear pain. Pus is draining
from the ear for 14 days according to
his mother.
Classify Steven’s condition.
◦Answer:
◦Acute Ear infection
Evidence:
Agonizing ear pain
Pus draining from the ear for 14
days.
situation

◦Gretchen is 10 mos old. She weighs 8.2

kgs. Her temperature is 37.5C. He has
cough.
◦Health worker checked for general
danger signs. Gretchen was able to
drink, was not vomiting, did not have
convulsion and was not abnormally
sleepy or difficult to awaken
◦ The health worker asked about Gretchen’s
cough. The mother said Gretchen had
been coughing for 5 days. She counted 43
breaths per minute. She did not see chest
indrawing.
◦He did not hear stridor when Gretchen
was calm.
◦Gretchen did not have diarrhea.
◦Next the health worker asked about
Gretchen’s fever. There is malaria risk.
The mother said Gretchen felt hot for 2
days. Gretchen did not have a stiff
neck.
 The health worker did a blood smear
and it turned out positive.
◦Gretchen has no rashes and no runny
nose. There is no measles now or within
the last 3 months. Then the health
worker checked for pus draining from
the eye or presence of mouth ulcer.
◦ There has been no cases of dengue fever in
the area.
◦ Classify Gretchen’s condition
◦ Classification:
◦ Malaria because of the (+) blood smear
and no evidence of measles.
Situation:

Nestor is 3 years old and weighs 9.4kgs.

His temp is 37 ºC. His mother says he
feels hot and he also has a cough.
The health worker checks for general
danger signs.
Nestor is able to drink and has not
vomited, does not have
convulsions, and is not abnormally
sleepy or difficult to awaken.
Nestor has been coughing for three
days and his breathing is counted
at 51breaths per minute.
He has no chest indrawing and does
not have any stridor.
Nestor has no diarrhea. Their family
took a trip to Palawan a month ago
because his father comes from the
place. He has felt hot for five days.
He has not had measles within the last
three months. He does not have stiff
neck, runny nose, and generalized
rash. It is not possible to take a blood
smear. There is no risk of dengue.
Situation
Kyla is 37 months old. She weighs 8kg.
He is not abnormally sleepy, no
cough and has no diarrhea.
The health worker checked her
nutritional status. She has no severe
wasting and no
Palmar pallor or edema on both feet. The
health worker check if her weight is
appropriate for his age.

Classify Kyla’s case

A. Kyla has severe malnutrition
B. Kyla has low weight
C. Kyla does not have low weight
D. Kyla has anemia.
Answer: B

Kyla has low weight

as evidenced by weight of 8kgs.
Identify the immunizations needed:
1. Ana is 2 weeks old
2. Ruel is 9 months old
3. Sarah is 6 weeks old
4. Cyril is 14 weeks old
5. Micah is 6 months old
Tell the mother to return immediately if
her child
◦Is not able to drink or breastfeed
◦Becomes sicker
◦Develops a fever
A child with simple cough or cold:
◦Fast breathing
◦Difficulty breathing

A child with diarrhea:

◦Blood in the stool
◦Drinking poorly
A child with fever: dengue
hemorrhagic fever unlikely:
◦Any signs of bleeding
◦Abdominal pain
◦vomiting
Look for :
Fast breathing-60 breaths per min.
Nasal flaring- widening of the nostrils as
the child breaths in.
Grunting- soft, short sounds when
breathing out
Bulging fontanels-soft spot on top of the
infants head.
Skin pustule-red spot or blisters that
contain pus.
Situation:
Carlo is a 3 week old infant. His weight
is 3.6kg. His axillary temperature is
37.7C. He is brought to the health
center because he is having difficulty
of breathing.
The health worker first checks the
infant for possible bacterial
infection. His mother says that
Carlo has not had convulsion. The
health worker counts 74 breaths
per minute. The second count is
70 breaths per minute.
He finds that Carlo has slight chest
indrawing and nasal flaring. He has no
grunting. The fontanels do not bulge.
There is no pus in the ear, the umbilicus
is normal and there are no skin
pustules. He does not have diarrhea.
Carlo is calm and awake, his
movements are normal.

Classify Carlo’s condition.

A. Possible serious bacterial infection
B. Local bacterial infection
C. Bacterial infection unlikely
D. No bacterial infection
◦Answer: A
◦Evidence: fever-37.7
◦Nasal flaring
◦Fast breathing- 70-74 breaths per
minute
◦Mild chest indrawing
Situation:
Kyle is 5 weeks old. His weight is 4kg. His
axillary temperature is 36.5C.
The health worker check for bacterial
infection. No pus in the umbilicus, no
pus in the ears and
No skin pustule.
He has diarrhea for 2 days. He is
restless and irritable. Has sunken
eyeballs.

Classify Kyle’s condition.

A. Sever dehydration
B. Some dehydration
C. No dehydration
D. Not enough signs for classification
Answer: B- some dehydration

Evidence:
Restless and irritable
Sunken eyeballs
Situation:
John is 5 weeks old. His weight is
4kg.His axillary temperature is
37C. His mother brought him to
the health center because of
difficulty of feeding. He feeds 2-3
times in 24 hrs and drinks water.
He is sucking poorly. The health
worker also checks if there are
white patches in his mouth and
found none.
His mother express difficulty in
positioning him for feeding.
◦ Classification: feeding problem or Low
Weight
◦ Evidence by:
◦ Difficulty in feeding
◦ feeds 2-3 times in 24 hrs
◦ Sucking poorly
◦ Difficulty in positioning
Counsel the mother

◦Recommendations for feeding and

care for development.
Feeding recommendations

◦ Birth up to 6 months- breastfeed

exclusively.
◦ Up to 6 of age breastfeed as often as the
child wants.
◦ Breastfeed when the child shows signs of
hunger such as sucking fingers or moving
lips.
◦Do not give other foods or fluids.
◦Exception is vitamins and medicines.
For Ages 6 months up to 12 months

◦Breastfeed as often as the child

wants.
◦Give complementary food gradually
as the child nears 12 months.
◦Give this food:
◦3 times per day if breastfeed
◦5 times per day if not breastfeed
◦Give small chewable items to eat with
fingers. Let the child feed himself but
provide help.
For Ages 12 months to 2 years

◦Breastfeed as often as the child wants.

◦Give adequate servings of family food
such as:
◦Rice, Camote, potato, fish, chicken,
meat, milk, eggs, green leafy
vegetables. Give it 5 times per day
For ages 2 years and Older

◦Give variety of family foods in 3

meals per day.
◦In between meals or 2 extra feedings
per day of foods such as:
◦Boiled camote, boiled banana, fruits
Assess

◦Difficulty in feeding- check the

mothers reason.
◦Use of bottle feeding
◦Lack of active feeding- not
encouraged to eat
◦Not feeding well during illness
◦Not giving protein source of food in
rice
◦Improper handling and use of breast
milk substitute.
Recommended Play

◦Up to 4 months
◦Clean, safe and colorful things from
the household such as metal cup,
plastic bowl.
◦They love to see people and faces, so
family members should carry the child.
◦Learning is through seeing, hearing,
feeling and moving.
Ages 4 months to 6 months

◦They like to reach for objects

and look at their hands and feet.
◦They put things in their mouth.
Ages 6 months to 12 months

◦ They enjoy making noise by hitting

or banging a cup with other
objects.
◦ They enjoy dropping things to see
where they fall and hear the
sounds they make or see if
someone picks them up.
Ages 12 months up to 2 years

◦They like putting things into boxes

and cans and taking them out.
◦They like to stack things up until they
fall down.
◦They want to move around and
explore.
◦They enjoy simple things from
household and from nature.
◦They need encouragement to try to
walk and practice it.
2 Years and Older

◦Help your child to count, name,

compare and match sizes, colors
and shapes.
◦They enjoy playing with other
children.
◦Make simple toys for your child.
Communication
birth up to 4 months

◦Look at your child’s eyes and smile

at her.
◦They communicate by crying.
◦They learn to trust that someone will
pay attention to their cries.
4 Months up to 6 months

◦They enjoy making new sounds like

squeals and laughter. They copy
what they hear.
◦Adults can coo and copy child’s
sound which prepare them for
talking later.
6months to 12 months

◦Children understand words before

they learn to say.
◦They notice when people express
anger and they are upset by it.
◦Teach them names and things.
12 Months up to 2 years

◦Ask your child simple questions.

◦Responds to your child’s attempt to
talk.
◦They can follow simple directions.
◦They can answer simple questions.
2 Years and Older

◦Encourage your child to talk. Answer

your child’s questions.
◦Teach you child stories, songs and
games.
◦They understand what is right and
wrong.
◦They should be corrected gently.
◦ Give the age group for the following
statement:
1. Give the child safe items to put in a
box
2. Give the child clean plastic cup to
bang against a plate.
3. Tell the child stories like “ ang
pagong at ang matsing”
4. Repeat the child’s cooing sounds.
5. Try to respond to cry immediately
and look into their eyes during
feeding.
Treat local infection

1. Treat eye infection with

tetracycline eye ointment
2. Dry the ear by wicking
3. Treat mouth ulcers with gentian
violet
4. Soothe the throat and relieve the
cough with safe remedy.
Ginger, tamarind, calamansi
Have a nice
Day !