Child Health-Approach in RCH-II
• The IMNCI approach is the
centrepiece of newborn and
child health strategy in RCH II.
UNDER-FIVE MORTALITY RANKINGS
COUNTRY
UNDER-FIVE MORTALITY
Rate(2007)
RANK
Afghanistan
257
2
Nigeria
189
8
Pakistan
90
43
Bhutan
84
45
India
72
49
Bangladesh
61
58
Nepal
55
62
Iraq
44
66
Maldives
30
88
China
22
107
Sri Lanka
21
110
Vietnam
15
126
Malaysia
11
140
The State of the World’s Children- 2009,
UNICEF
Recent trends in Neonatal and Infant
Mortality Rate
70
60
58
58
57
55
53
50
40
37
37
37
36
35
30
26
28
28
29
27
SRS 2004
SRS 2005
SRS 2006
SRS 2007
SRS 2008
20
10
0
Infant Mortality Rate
Neo-Natal Mortality Rate
Early Neo-Natal M.R.
Neonatal Mortality Rate shows stagnation; need to act
IMR high in Bihar, Chhattisgarh, Madhya Pradesh, Orissa,
Rajasthan, Uttar Pradesh and Assam
80
70
Per 1000 live births
60
50
40
30
70 69
67
Infant Mortality Rate
SRS 2008
64 63
57 56
53
52 50
46 45
41
35 33
31
20
12
10
0
10
Distribution of deaths of children less
than 5 Years, by cause, the world, 1990
and projected for 2020
The 5 main killers of
children:
ARI, diarrhoea,
measles, malaria
and malnutrition
1990
2020
55%
52%
Perinatal
conditions
Other
communicable
diseases
Non-communicable
diseases
Injuries
19%
5%
9%
7%
18%
11%
12%
11%
For many sick children a single
diagnosis may not be apparent or
appropriate
Presenting complaint
Possible cause or associated
condition
Cough and/or fast breathing
Pneumonia
Severe anaemia
P. falciparum malaria
Lethargy or unconsciousness
Cerebral malaria
Meningitis
Severe dehydration
Very severe pneumonia
Measles rash
Pneumonia
Diarrhoea
Ear infection
"Very sick" young infant
Pneumonia
Meningitis
Sepsis
WHO/ UNICEF -Integrated Approach
 3 out of 4 children who seek
health care are suffering
from at least one of the five
conditions
 Some children are often
suffering from more than one
condition, making a single
diagnosis impossible
 Such children need complete
assessment and combined
therapy for successful
treatment.
Integrated Management
of Childhood Illness
(IMCI) - Focuses on the
child and not on the
illness
Integrated
Management of
Childhood Illness
(IMCI) is a costeffective approach
Causes of Deaths 0-4 years- 2001-03
Office of Registrar General, India
Perinatal conditions
3.4
3.2
Resp Infections
2.7 1.5
2.8 2.7
33
Diarrhea
Infectious and Parasitic
diseases
Ill defined
11
Injuries
14
Nutritional def
22
Malaria
Cong. Anamolies
PUO
Share of under-five mortality in India
Neonatal deaths
50%
Infant deaths within 7 days of birth
40%
Infant deaths
76%
Infant deaths between
7 days of birth and within 28 days
Infant deaths between 28 days
and within one year of birth
Child deaths between one
year and within five years of birth
Source : SRS 2007
10%
26%
24%
IMCI to IMNCI-INDIA
Major Adaptations
• The entire 0-5 year period covered including the first week of
life
• 50% of training time for management of young infants (0-2
months)
• The order of training reversed; now begins with management
of young infants
• Reduced training duration (8 days), separate training materials
for physicians & health workers
• Management now consistent with current policies of the
MOHFW, DWCD and NVBDCP
IMNCI as a key strategy for improving
child health
Management
of sick newborn
& children
Nutrition
Immunization
Integrated Management of
Neonatal & Childhood Illness
Other disease
Prevention &
Promotion of
growth and
development
What Needs to be Done in IMNCI
 Improving the case management
skills of health workers
• Improving the health system for
effective management of childhood
illness
• Improving family and community
practices
Case Management Process
Two groups:
(A)
Young infants :
From birth up to 2 months of age.
(B)
Older children :
From 2 months up to 5 years of age.
What does IMNCI Offer
• IMNCI guidelines address most but not all of the
major reasons a sick infant and child is brought to
a clinic
• Only a limited number of signs based on evidence
are used to detect a disease
• A combination of individual signs leads to action
oriented colour coded classification(s)
• IMNCI management includes a limited number of
drugs and encourages active participation of
caretakers
• Counselling of caretakers is an essential
component
Core interventions to improve child
survival
• Combating pneumonia/sepsis
• Combating diarrhoea
• Nurturing newborns
(and their mothers)
• Infant feeding
• Immunization
• Combating malaria
IMNCI
Standard Clinical Guidelines
“Golden” paediatric standard
Complete
examination
all signs
and
systems
Preliminary
Diagnosis
Laboratory
examination
Differential
Diagnosis
Final
Diagnosis
Treatment
strategy
Treatment
procedures
“IMNCI” approach
Focused Assessment
Danger signs
Main Symptoms
Nutritional status
immunisation status
other problems
Classification
Need to Refer
Specific treatment
Treatment
Identify
treatment
Treat
Counsel & Follow-up
Counsel
Caretakers
Follow-up
Home management
• Essential Investigations
Advise to
caretakers
Follow- up
Case Management Process
 Assess
the Child.
 Classify the Illness.
 Identify Treatment.
 Treat the Child.
 Counsel the Mother
 Give Follow-Up
Care.
Assess the Child
Tools for
assessment:
 Ask,
 Look,
 Listen,
 Feel.
and
Classify The Illness
“Classify the illness” means making a decision
on the severity of the illness according to the
child’s major symptoms.
 Classifications are not diagnoses.
 They are categories that are used to
determine treatment.

PINK: Patient requires URGENT hospitalization.
Give pre-referral treatment and
Refer URGENTLY to hospital.
YELLOW: Specific medical treatment and advice,
as you do in your OPD or Clinic.
GREEN: Simple advice on home-management.
May require some home made safe remedy.
IDENTIFY TREATMENT




This is further direction to management
If a child needs urgent referral (hospitalization),
give pre-referral treatment
If a child needs treatment at home, explain
mother how to do it home
If a child needs immunization, give it
TREAT THE CHILD




This explains complete treatment to be given at
clinic and at home
This includes teaching the mother (or caretaker)
how to give oral drugs, how to feed and give
fluid during illness, and how to treat local
infection at home
Return for follow up
When to return immediately
COUNSEL THE MOTHER




Assess and Counsel the
mother to solve any
feeding problem found
Counsel on home care
Counsel on when to
return immediately
Counsel the mother about
her own health
Classify ALL YOUNG INFANTS
SIGNS
Convulsion or
 Fast Breathing (60 breaths per minute or more) or
 Severe chest indrawing or
 Nasal flaring or
 Grunting or
 Bulging fontanel or
 10 or more skin pustules or a big boil or
 If axillary temperature 37.50C or above (or feels hot to
touch) or temperature less than 35.50C (or feels cold to
touch) or
 Lethargic or unconscious or
 Less than normal movement
CLASSIFY AS

Umbilicus red or draining pus or
o Pus discharge from ear or
o < 10 skin pustules
o
POSSIBLE SERIOUS
BACTERIAL INFECTION
LOCAL BACTERIAL
INFECTION
Classification- Pneumonia
VIDEOS & PHOTO BOOK
Good attachment to Breast
lower lip is curled outward
chin touches
the breast
baby’s mouth is wide open
lower portion of
the areola is not
visible
VIDEOS & PHOTO BOOK
Poor attachment to Breast
VIDEOS & PHOTO BOOK
Breastfeeding- Correct Positioning
Is this baby well positioned ?
VIDEOS & PHOTO BOOK
SKIN PINCH- DEHYDRATION ASSESSMENT
VIDEOS & PHOTO BOOK
MORE THAN 10 SKIN PUSTULES
VIDEO
• GRUNTING- Short expiratory sound, signifies
infant having difficulty in breathing- Severe
illness
• 2 Grunting.wmv
VIDEO
SIGNS OF SEVERE PNEUMONIA
• CHEST INDRAWING- Lower chest wall goes in
during inspiration
• STRIDOR- Harsh sound when child breathes in
• 2 Severe Respiratory Distress_Large.wmv
VIDEO
• VISIBLE SEVERE WASTING- severe wasting of
the shoulders, arms buttocks and legs with
ribs easily seen- MARASMUS
• 11Severe malnutrition_Large.wmv
REMEMBER- SEVERE CLASSIFICATIONS
Sick Young Infant age up
to 2 months
• Possible serious bacterial
infection
• Severe Jaundice
• Severe Dehydration
• Severe Persistent Diarrhea
• Severe Dysentery
• Not able to feed- Possible
serious bacterial infection
OR Severe Malnutrition
Sick Child age 2 months up
to 5 years
• Severe Pneumonia Or Very
Severe Disease
• Severe Dehydration with
another severe classification
• Severe Persistent Diarrhea
• Very Severe Febrile Disease
• Severe Complicated Measles
• Mastoiditis
• Severe Malnutrition
• Severe Anemia
ACTION- PRE- REFERRAL TREATMENT & URGENT
REFERRAL
Hospital is the best place for
treating a very sick infant/child
But if Referral is not possible,
IMNCI Guidelines can save a life !
TAKE HOME MESSAGE
IMNCI--Colour coded case management
strategy
• PINK CLASSIFICATION: Child needs inpatient care,
Provide Pre-referral treatment and Refer Urgently
• YELLOW CLASSIFICATION: Child needs specific
treatment, provide it at home (e.g. antibiotics, antimalarial, ORT)
• GREEN CLASSIFICATION: Child needs no medicine,
advise home care
CONCLUSION
The IMNCI Strategy focuses on the diseases of
the childhood that cause the greatest global
burden.
 An integrated approach is needed because the
overlap in the signs and symptoms of the
major diseases is common.

Conclusion (continued)
It is important to treat the child as a whole,
not simply the most apparent disease.
 The IMNCI approach ensures a complete
assessment of a sick child, provision of
treatment and counseling the mother to
improve health practices at home and to
promote health seeking behavior.

THANK YOU