Integrated Management of
Childhood Illnesses (IMCI)
Dr. Pushpa Raj Sharma
DCH, DTCH, FCPS
Professor of Child Health
Institute of Medicine, Kathmandu, Nepal
Burden of the Paediatric
Disease in Nepal
40,000 deaths are pneumonia related.
30, 000 deaths are diarrhea related
40, 000 deaths are nutrition related
50% deaths are related with neonatal
problems.
Burden of these diseases are
due to:
Unskilledhealth worker
Bad family health practices
Unequipped health facility
Unavailability of health resources
Problems in different age groups:
Neonatal period: resuscitation problems,
infections, metabolic.
Under five: infections, nutritional.
Preadolescent: developmental, worms,
skin.
Adolescent: psychological, sexual habits,
drugs.
Common causes of morbidity
and mortality
Morbidity Mortality
Acute respiratory Pneumonia
infections. Severe dehydration
Diarrhea Meningitis/encephalitis
Fever Cerebral malaria
Ear infections Kwashiorkor/marasmus
Malnutrition Sepsis
Local skin infections Hypothermia
Oral thrush Hypoglycemia
Previous programmes
Training of health workers
Vertical programmes
Child problems were seen as a
separate issues
Very little counseling training
Little emphasis on clinical practice
What is needed?
National goal for reducing the morbidity
and mortality.
Holistic approach.
Improving family practices.
Equipping the health facility.
Upgrading the health workers skills.
Emphasis on counseling.
How to do it?
Targeting the problem.
All the components in one part.
Optimal use of resources.
Evidence based.
Feasible.
Acceptable by community.
Sensitivity and specificity
100% Sensitivity
Specificity
Clinical signs
Investigations
Sensitivity: positive with disease
Specificity: negative without disease
The answer
Integrated
Management of
Childhood
Illnesses
IMCI
How it helps?
Identifies a child who needs urgent referral.
Gives evidenced based clinical signs for the
diagnosis of common problems.
Provides guidelines for the appropriate
treatment.
Educates the parent.
Upgrades the health care facility.
Follow-ups the child.
Conditions that it covers
Respiratory: pneumonia, cough/cold.
Diarrhea: acute watery, dysentery, persistent.
Fever: malaria, measles, meningitis,
encephalitis.
Ear problems: mastoditis, acute and chronic
infections.
Nutritional: kwashiorkor/marasmus, anemia
Conditions that it covers
Nutritional: feeding problems, breast feeding,
counseling.
Neonatal sepsis.
Local infections.
Hypoglycemia, hypothermia.
Oral thrush
Immunization.
Vit. A supplementation
Deworming.
What it contains?
2 months up to 5 years
Simple clinical signs of severe disease.
Simple clinical signs to diagnose pneumonia.
Simple clinical signs to identify three clinical
types of diarrhea.
Simple clinical signs to identify malaria.
Simple clinical signs to identify ear infections.
Simple clinical signs to identify malnutrition.
What it contains?
Young infant.
Simple clinical signs to identify for
referral.
Simple clinical signs to treat at health
facility.
Simple signs to identify good breast
feeding.
What it contains?
General
Simple guidelines for nutrition.
Simple guidelines for treatment of severe
diseases, pneumonia, diarrhoea,
dysentery,fever,malaria, ear infections, local
infections, anaemia, malnutrition.
Guidelines for counseling.
Home care messages, safe practices.
Immunization, vit A, deworming information.
What are the evidences?
Trained health worker identified target
disease better than doctors.
Over prescriptions were reduced.
Parents were more satisfied.
Cost effective.
Mortality and morbidity reduced.
Health facility better equipped.
Some examples
Simplequestions and simple
observations to find out the problem:
severe disease.
Does child vomits every thing?
Is the child able to drink?
History of convulsions?
Is the child lethargic or unconscious?
Four main symptoms:
2 months up to 5 years
Does the child has cough or difficulty
breathing?
Does the child has diarrhea?
Does the child has fever?
Does the child has ear problem?
Assess every child for:
2 months up to 5 years
Malnutrition:
Weightfor age
Oedema
anaemia
Immunization
Vitamin A supplementation
Deworming
If the answer is yes:
For how long?
Associated symptoms?
Classify the illness
Identify treatment
Treat the child
My child has cough for 2 days:
(example)
Observe for general danger signs.
If present refer the child with first dose of
antibiotics.
Count the respiratory rate: 60/50/40.
Fast breathing indicates pneumonia.
Look for indrawing.
If present indicates severe pneumonia and needs
referral.
Look and listen for stridor in a calm child.
If present indicates severe disease and referral is
needed.
Classify the disease (example)
Age 9 months: no general danger signs, no
chest indrawing, no stridor, no fast breathing.
No pneumonia (cough and cold).
Age 12 months: chest indrawing.
Severe pneumonia.
Age 4 months: fast breathing only.
Pneumonia.
Age 6 months: presence of general danger
sign.
A child with very severe disease.
Identify treatment (example)
No pneumonia:
Safe home remedies/ paracetamol/ when to
return? Counsel.
Pneumonia:
Antibiotic/paracetamol/safe home remedies/when
to return? Counsel.
Severe pneumonia/very severe disease:
First dose of antibiotic/ referral note/ counsel.
Treat the child
Essential drugs.
Safe home care.
Duration of treatment.
When to return.
Change of treatment.
Counsel the parent.
Other problems.
Other Options in IMCI
Neonatal problems of first week
Developmental pediatrics
Perinatal problems
Injury
……….
IMCI : model for other
problems in pediatric diseases
Entry questions.
Threading questions.
Evidenced based specific clinical signs.
Treatment.
Follow-up.
Referral.
Counsel.
History of IMCI in Nepal
1995: IMCI Activities started. District
identified, Saptari.
1996: Orientation meeting, nutrition survey,
necessary adaptations to generic materials.
1997: Nepali translation, TOT courses.
1998: Follow-up visits, review meeting, pre-
service training.
Expansion: at present 13 district.
Thank you.
Any questions?
Any clarifications?
Any suggestions for this presentation?
