IMCI Group 1 BSN 3-A Brgy.

Manduyog, Alimodian, Iloilo

Integrated Management of Childhood

Illness (IMCI)
Background
Every day, millions of parents seek health care for their sick children, taking them to
hospitals, health centres, pharmacists, doctors and traditional
healers. Surveys reveal that many sick children are not properly
assessed and treated by these health care providers, and that their
parents are poorly advised. At first-level health facilities in low-
income countries, diagnostic supports such as radiology and
laboratory services are minimal or non-existent, and drugs and
equipment are often scarce. Limited supplies and equipment,
combined with an irregular flow of patients, leave doctors at this
level with few opportunities to practice complicated clinical
procedures. Instead, they often rely on history and signs and symptoms to
determine a course of management that makes the best use of the available
resources.

These factors make providing quality care to sick children a serious challenge. WHO
and UNICEF have addressed this challenge by developing a strategy called the
Integrated Management of Childhood Illness (IMCI).

What is IMCI?

IMCI is an integrated approach to child health that focuses on the well-being of the
whole child. IMCI aims to reduce death, illness and disability, and to promote
improved growth and development among children under five years of age. IMCI
includes both preventive and curative elements that are implemented by families
and communities as well as by health facilities.

The strategy includes three main components:

 Improving case management skills of health-care staff

 Improving overall health systems
 Improving family and community health practices.

In health facilities, the IMCI strategy promotes the accurate identification of

childhood illnesses in outpatient settings, ensures appropriate combined treatment
of all major illnesses, strengthens the counselling of caretakers, and speeds up the
referral of severely ill children. In the home setting, it promotes appropriate care
seeking behaviours, improved nutrition and preventative care, and the correct

Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit
IMCI Group 1 BSN 3-A Brgy. Manduyog, Alimodian, Iloilo

implementation of prescribed care.

Why is IMCI better than single-condition approaches?

Children brought for medical treatment in the developing world are often suffering
from more than one condition, making a single diagnosis impossible. IMCI is an
integrated strategy, which takes into account the variety of factors that put children
at serious risk. It ensures the combined treatment of the major childhood illnesses,
emphasizing prevention of disease through immunization and improved nutrition.

How is IMCI implemented?

Introducing and implementing the IMCI strategy in a country is a phased process

that requires a great deal of coordination among existing health programmes and
services. It involves working closely with local governments and ministries of health
to plan and adapt the principles of the approach to local circumstances. The main
steps are:

 Adopting an integrated approach to child health and development in the

national health policy.
 Adapting the standard IMCI clinical guidelines to the country’s needs,
available drugs, policies, and to the local foods and language used by the
population.
 Upgrading care in local clinics by training health workers in new methods to
examine and treat children, and to effectively counsel parents.
 Making upgraded care possible by ensuring that enough of the right low-cost
medicines and simple equipment are available.
 Strengthening care in hospitals for those children too sick to be treated in an
outpatient clinic.
 Developing support mechanisms within communities for preventing disease,
for helping families to care for sick children, and for getting children to clinics
or hospitals when needed.

IMCI has already been introduced in more than 75 countries around the world.

What has been done to evaluate the IMCI strategy?

CAH has undertaken a Multi-Country Evaluation (MCE) to evaluate the impact,

cost and effectiveness of the IMCI strategy. The results of the MCE support planning
and advocacy for child health interventions by ministries of health in developing
countries, and by national and international partners in development. To date, MCE
has been conducted in Brazil, Bangladesh, Peru, Uganda and the United Republic of
Tanzania.

Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit
IMCI Group 1 BSN 3-A Brgy. Manduyog, Alimodian, Iloilo

The results of the MCE indicate that:

 IMCI improves health worker performance and their quality of care;

 IMCI can reduce under-five mortality and improve nutritional status, if
implemented well;
 IMCI is worth the investment, as it costs up to six times less per child
correctly managed than current care;
 child survival programmes require more attention to activities that improve
family and community behaviour;
 the implementation of child survival interventions needs to be complemented
by activities that strengthen system support;
 a significant reduction in under-five mortality will not be attained unless
large-scale intervention coverage is achieved.

Steps in the IMCI Case Management Process:

1. Assess and Classify

2. Identify Treatment
3. Treat
4. Counsel the Mother
5. Follow-Up

A. Assess and Classify Sick Children 2 months up to 5 Years

1. Determine which age group the child belongs:

1 week up to 2 months
2 months up to 5 years
2. Record the child’s data : Name, Age in months, Weight in kg., temperature, etc.

3. Ask the mother what the child’s problems are.

4. Determine if this is an initial or follow – up visit:
Initial visit – 1st visit for this episode of an illness or problem
Follow-up visit- the child has been seen a few days ago for the same illness
- if the child’s condition improved, still the same or is getting
better

4. Check for general danger signs:

a. not able to drink or breastfeed

Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit
IMCI Group 1 BSN 3-A Brgy. Manduyog, Alimodian, Iloilo

 too weak to drink and is not able to suck or swallow when offered a drink
or
Breast-feed
 if not sure: ask mother to offer child a drink of clean water or breast milk
 A child may have difficulty sucking when his nose is blocked. If the nose
is blocked, clean it.
b. vomits everything
 a child is not able to hold anything down at all
 if in doubt, offer the child water
c. convulsions (during this illness)
 arms and legs stiffen because muscles are contracting
 the child may lose consciousness or not be able to respond to spoken
directions or handling, even if eyes are open
 “fits” or “spasms” or “jerky movements”
Note: Shiver is not convulsion. There is no loss of consciousness.
d. abnormally sleepy or difficult to awaken
 drowsy and does not show interest in what is happening around him
 stare blankly and appear no to notice what is going on around him
 does not respond when touched, shaken or spoken to
Note: 1. If the child is asleep and has cough or difficult breathing, count the
number
of breaths first before you try to wake the child.
2. If there is any general danger sign, complete the assessment and any
pre-referral treatment immediately so referral is not delayed.

5. Assess and classify cough or difficult breathing

 2 Common Causes of Pneumonia
1. Stretococcus pnemoniae
2. Hemophilus influenzae
 2 Causes of Death
1. hypoxia – too little oxygen
2. sepsis – generalized infection

 Health workers can identify almost all causes of pneumonia by checking

for 2 clinical signs: 1. fast breathing – body’s response to stiff lungs and
hypoxia
2. chest indrawing

Assess cough or difficult breathing:

Does the child have cough or difficult breathing? “fast” or “noisy” or “interrupted”?

Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit
IMCI Group 1 BSN 3-A Brgy. Manduyog, Alimodian, Iloilo

* If the answer is NO, look back to see if you think the child has cough or difficult
breathing.
 how long?
chronic cough – more than 30 days
- may be sign of tuberculosis, asthma, whooping cough or
another
problem
 fast breathing
a. count the breaths in one minute
1. child must be quiet and calm
2. no feeding, crying or angry
 Ask the mother to lift the child’s shirt. If you are not sure about the
number of breaths you counted, repeat the count.

b. cut-off for fast breathing:

if the child is: fast breathing is:
2 months up to 12 months 50 breaths/ minute or
more
12 months up to 5 years 40 breaths/ minute or
more

Determine if the child is breathing IN or breathing OUT

 chest indrawing – the lower chest wall goes IN when the child breaths IN
NORMAL: the whole chest wall and abdomen move OUT when the child
breaths
IN
Best position : lying down
Conditions : clearly visible
Note: intercostals indrawing or intercostals retractions and subcostal
indrawing are not chest indrawing.

 Look or listen for stridor.

Stridor – harsh noise made when the child breaths IN
- happens when there is swelling of the larynx, trachea, or epiglottis
Put your ear near the child’s mouth and look at the movement of the
abdomen to determine if child is breathing IN or OUT
wet noise - blocked nose
wheezing - harsh noise while breathing OUT; not stridor

CLASSIFY COUGH OR DIFFICULT BREATHING

6. Assess and classify diarrhea

diarrhea – loose or watery stool
- defined as 3 or more loose or watery stools in a 24 – hour period

Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit
IMCI Group 1 BSN 3-A Brgy. Manduyog, Alimodian, Iloilo

Assess:
 how long?
 blood in stool
 signs of dehydration

If YES, asses for:

 dehydration
 persistent diarrhea – 14 days or more
 Dysentery
Asses for dehydration:
 Abnormally sleepy or difficult to awaken
 Restless and irritable: (all the time)
 Sunken eyes: If not sure, ask the mother if the child’s eyes look unusual.
 Offer the child fluid :
Not able to drink - if he is not able to take fluid in his mouth and swallow it
Drinking poorly – if the child is weak and cannot drink without help.
Drinking eagerly, thirsty – reaches out for the cup or spoon when you offer water.
 Pinch the skin of the abdomen:
Goes back very slowly – longer than 2 seconds
Goes back slowly – the skin stays up for even a brief time after release.

CLASSIFY DIARRHEA FOR ;: DEHYDRATION

PERSISTENT DIARRHEA
DYSENTERY

7. Assess Fever:

A child has the main symptom fever if:

- the child has history of fever – no fever now but had fever within 72
hours or
- the child feels hot or
- the child has an axillary temperature of 37.5 C or above

Decide malaria risk:

- child lives in malarious area or

- has been in a malaria risk area in the past 4 weeks.

Look or feel for stiff neck:

- look to see if the child moves and bends his neck easily as he looks
around or

Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit
IMCI Group 1 BSN 3-A Brgy. Manduyog, Alimodian, Iloilo

- draw the child’s attention to his toes or

- gently support his back and bend the head forward toward hid chest.

Look for runny nose ( not history of runny nose)

Look for signs of Measles: generalized rash and any one of the following:
cough, runny nose, or red eyes. Measles rash: begins behind the ears and on
the neck, spreads to the face, and to the rest of the body; does not have
vesicles or pustules; does not itch.

If the child has measles now or within the last 3 months, assess for:
- mouth ulcers – painful open sore on the inside of the mouth and lips or
tongue
- pus draining from the eye
- clouding of the cornea – hazy area in the cornea

Assess for Dengue Hemorrhagic Fever all children two months of age or
older.-
Look and feel for signs of bleeding and shock:
- bleeding from the nose and gums
- skin petechiae – small hemorrhages in the skin; look like small dark
red spots or patches in the skin; not raised, not tender; if you stretch
the skin they do not lose their color.
- Cold and clammy extremities
- If with cold and clammy extremities, check for slow capillary refill
( longer than 3 seconds
- Perform the tourniquet test if: there are no signs in the ASK or LOOK
and FEEL, the child is 6 months or older, and the fever is present for
more than 3 days.

CLASSIFY FEVER

8. Assess Ear Problem

Assess the child for :
- Ear pain
- Ear discharge ; Present less than 2 weeks – Acute ear infection
Present 2 weeks or more – Chronic Ear Infection
- Tender swelling behind the ear

CLASSIFY EAR PROBLEM

9. Check for malnutrition and anemia:

Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit
 IMCI Group 1 BSN 3-A Brgy. Manduyog, Alimodian, Iloilo

Look for visible severe wasting – a child with visible severe wasting has marasmus, a
form of severe malnutrition.. A child has this sign if he is thin, has no fat, and looks like
skin and bones.

Look for palmar pallor – a sign of anemia

Some palmar pallor – the skin on the child’s palm is pale
Severe palmar pallor – the palm is very pale or so pale that it looks white

Look and feel for edema of both feet – the child may have kwashiorkor, a form of severe
malnutrition.

Determine weight for age:

Very low weight for age – child’s weight is below the bottom curve of a weight for age
chart.

CLASSIFY NUTRITIONAL STATUS

10. Check the child’s immunization status.

11. Check the child’s Vitamin A status.

12. Assess other Problems.

B. Management of the Sick Young Infant Age 1 Week Up to 2 Months

1. Assess the sick young infant

Check the young infant for possible bacterial infection.

1. Ask if the child had convulsion at any time after birth.

2. Count the number of breaths in one minute. Fast breathing is 60 breaths
per minute or more.
3. Look for severe chest indrawing. Mild chest indrawing is normal in a
young infant or young child. Severe chest indrawing is very deep and
easy to see.
4. Look for nasal flaring – widening of the nostrils when the young infant
breaths in.
5. Look and listen for grunting – soft, short sounds when breathing out.

Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit
IMCI Group 1 BSN 3-A Brgy. Manduyog, Alimodian, Iloilo

6. ‘Look and feel for bulging fontanelle. Fontanelle is the soft spot on the top
of the young infant’s head, where the bones of the head have not formed
completely.
7. Look at the umbilicus – is it red or draining pus?
8. Measure temperature or feel for fever or low body temperature. Fever
(axillary temperature 37.5 C or more; rectal temperature 38 C or more).
Hypothermia ( axillary temperature below 35.5 C; rectal temperature
below 36 C).
9. Look for skin pustules – red spots or blisters which contain pus. A severe
pustule is large of has redness extending beyond the pustule.
10. LOOK: See if the child is abnormally sleepy or difficult to awaken.
11. LOOK at the young infant’s movement. Are they less that normal?

CLASSIFY ALL SICK YOUNG INFANT FOR BACTERIAL INFECTION

Assess Diarrhea

- For how long?

- Is there blood in the stool?
- Look at the young infant’s general condition. Is it “Abnormally sleepy
or difficult to awaken” or “Restless and irritable”?
- Look for sunken eyes.
- Pinch the skin of the abdomen. Does it go back very slowly? Or
slowly?

CLASSIFY DIARRHEA

Check for feeding problem or low weight.

Assess Breastfeeding.

4 Signs of Good Positioning;

- with infant’s head and body straight
- facing her breast, with infant’s nose opposite her nipples
- with infant’s body close to her body
- supporting infant’s whole body, not just neck and shoulders

4 Sign of Good Attachment:

- Chin touching breast
- Mouth wide open
- Lower lip turned outward
- More areola visible above than below the mouth.

Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit
IMCI Group 1 BSN 3-A Brgy. Manduyog, Alimodian, Iloilo

Suckling effectively – the infant suckles with slow, deep sucks and sometimes
pauses. You may see or hear the infant swallowing.

Not suckling effectively – he is taking only rapid, shallow sucks. You may
see indrawing of the cheeks. You do not see or hear swallowing.

Not suckling at all – not able to suck breastmilk into his mouth and swallow.

Look for ulcers or white patches in the mouth (thrush). Thrush looks like
milk cuds on the inside of the cheek, or thick white coating of the tongue. Try
to wipe it off. Milk curds will be removed but thrush will remain.

Check the Young Infant’s Immunization Status

Assess Other Problems

REFERENCES:
http://www.who.int/child_adolescent_health/topics/prevention_care/child/imci/en
/index.html

http://www.scribd.com/doc/2224624/Handouts-IMCI

Alforo/Alonsabe/Deferia/Ichon/Lerona/Ong/Rementilla/Santillan/Tajanlangit