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 related40, 000 deaths are nutrition related50% deaths are related with neonatal

problems.

Burden of these diseases are due to:

Unskilled health worker Bad family health practicesUnequipped health facilityUnavailability 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

Acute respiratory infections.

Diarrhea Fever Ear infections Malnutrition Local skin infections Oral thrush

Mortality Pneumonia Severe dehydration Meningitis/encephalitis Cerebral malaria Kwashiorkor/marasmus Sepsis Hypothermia Hypoglycemia

Previous programmes

Training of health workersVertical programmesChild problems were seen as a

separate issuesVery little counseling trainingLittle 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 signsInvestigations

Sensitivity: positive with diseaseSpecificity: negative without disease

The answer

IntegratedManagement ofChildhood 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

Simple questions 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: Weight for age Oedema anaemia

ImmunizationVitamin A supplementationDeworming

If the answer is yes:

For how long?Associated symptoms?Classify the illness Identify treatmentTreat 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 weekDevelopmental pediatricsPerinatal 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?